A San Diego psychiatrist has been sentenced to prison for fraudulent claims to Tricare, and ordered to pay $783,764 in restitution.
Marco Antonio Chavez “used these ill-gotten gains to buy himself luxuries including a red 2016 Jaguar and thousands of dollars’ worth of David Yurman jewelry,” stated a press release from the U.S. Attorney’s Office in the Southern District of California.
The 40-year-old Chavez was sentenced in federal court to 21 months in prison. The maximum penalty for health care fraud is 10 years in prison and a $250,000 fine. In August, 2019, Chavez pleaded guilty to felony health care fraud.
Over time, Chavez submitted about $928,800 in false and fraudulent claims to Tricare , and Tricare paid $783,764 on those claims.
Chavez became a Tricare network provider in April, 2013, providing psychiatry services, including therapy and prescription medications for children and adults. According to prosecutors, he used his access to the web-based system to submit fraudulent claims to Tricare using his unique personal security code to avoid review by other billing staff, according to the release. He then arranged for those federal funds to be paid directly into his personal account.
Chavez used information from patients to submit claims for nonexistent care, according to prosecutors. In one example, he billed Tricare for 80 dates of service, when he actually saw the patient on just three different occasions. His office staff submitted the claims for those three occasions; Chavez submitted the other 77 claims directly, according to the release. Of those claims, 21 included dates for service before that patient’s initial visit. Another patient saw Chavez on five occasions, yet Chavez submitted another 71 claims for service when he didn’t actually see the patient. Those two incidents cited by prosecutors happened in 2013 and 2014.
Prosecutors said Chavez tried to avoid detection through a variety of means. He told patients that they might see entries on their Explanation of Benefits forms from Tricare that they wouldn’t recognize.
When the Tricare contractor conducted an audit and asked for certain patient files, he claimed he had already sent the files, when he knew the files didn’t exist, according to the release.
In addition to Assistant U.S. Attorney Valerie Chu, the FBI and Defense Criminal Investigative Service worked on the case.
“Dr. Chavez’ conduct is a particularly egregious example of fraud against the TRICARE program in that his greed clearly took priority over his patients’ trust and well-being,” said Bryan D. Denny, Special Agent in Charge of the Defense Criminal Investigative Service, Western Field Office, in a statement in the release.
“The doctor’s sentencing should serve notice to other unscrupulous healthcare providers that any unprincipled actions that corrupt the integrity of the Tricare program and ultimately degrade the quality of health care provided to military service members and their families will be vigorously investigated by DCIS and its law enforcement partners.”
In a separate action on June 23, the Medical Board of California issued an order revoking Chavez’s medical license, related to allegations that Chavez was treating patients while under the influence of a drug or alcohol, according to Board documents.
In May, 2018, NBCSanDiego.Com reported that a judge had suspended Chavez’s license after he admitted to drinking a pint of vodka before treating patients.
In Board documents, an investigator who visited Chavez’s office stated Chavez had told him he drank two eight ounce glasses of vodka mixed with cloves at 6 a.m. and 7 a.m. that morning, because it was his mother’s home remedy to stop his drinking. There were patients in the waiting room when the investigator visited.
Karen has covered military families, quality of life and consumer issues for Military Times for more than 30 years, and is co-author of a chapter on media coverage of military families in the book "A Battle Plan for Supporting Military Families." She previously worked for newspapers in Guam, Norfolk, Jacksonville, Fla., and Athens, Ga.