A rocky six years dogged Houston physician Benjamin Echols even before his February indictment for fraud and accusations that he accepted kickbacks from a home health care company that earned $6.4 million in Medicare payments.
Yet, a Houston Chronicle investigation found the 62-year-old gastroenterologist still keeps watch over nine private Emergency Medical Services ambulance companies that also collected Medicare money - at least $19.4 million in the past five years.
Echols is one of dozens of local doctors known as "medical directors," whose job it is to make sure that EMS companies follow proper medical standards.
Before his indictment, Echols had been cited by the Texas Medical Board for poor record keeping, failure to manage patient pain medications and helping a patient defraud the state's worker's compensation program. At one point, the state forced Echols to pay $7,500 in fines, attend classes about how to do his job and assigned a doctor to watch over him.
But as long as he has a valid physician's license, which he does, he can continue to serve as medical monitor for ambulance companies. His attorney declined to comment.
Up to $2,500 a month
In the greater Houston area, where hundreds of private EMS companies have collected nearly $500 million in federal dollars over the last five years, the job of medical director has turned into a lucrative industry of its own.
The doctors who work for the nearly 400 EMS companies are paid anywhere from $800 to $2,500 a month for the services, the Chronicle found. In some cases, just one round trip EMS transport - a $1,000 check from taxpayers - covers the cost.
Among other things, medical directors supervise "quality assurance" for the companies.
But at least nine Houston doctors have faced sanctions for everything from defrauding the government to improperly doling out prescription drugs.
Despite a 12-year-license suspension, Peter Okose monitors three EMS companies. In 2006, the state board suspended his license because his "continuation in the practice of medicine presented a continuing threat to the public welfare."
Okose failed to maintain proper records for 13 patients, failed to treat them properly and prescribed drugs improperly, according to state board documents. He told the licensing authority in 2006 he was seeing up to 400 patients a week, or 80 patients a day, a "massive amount," the board found. The next year, he violated the terms of his suspension and was ordered to pay a $6,000 fine.
Last year, Okose was indicted for unlawful distribution of controlled substances and faces trial in federal court. He still is permitted to practice in a limited way. Okose's attorney, Kent A. Schaffer said his indictment does not interfere with his duties as a doctor and believes Okose will be exonerated.
William Mack, a medical director for as many as 28 private ambulance companies that have collected at least $7.2 million since 2005, kept his license after a medical board investigation revealed he had been sued for fraudulent Medicaid claims in the mid-1990s. In one year, his income increased by $500,000. He was forced to repay the federal government more than $1.4 million. It's unclear if the payment was made.
He also billed for procedures performed at his "in-house" laboratory. The board ordered him to complete 120 hours of community service and 10 hours of medical education.
Mack did not return calls for comment.
Medical directors approve an ambulance company's medical "protocols" - which guide emergency medical technicians and paramedics when they are dealing with patients in transit. They are required to notify the Texas Department of State Health Services that they are working for an EMS company but need only provide proof of a valid physician's license.
$45 million in 5 years
Other disciplined doctors, according to state records, include:
Donald Gibson, reprimanded in 2008 for overprescribing painkillers, was placed on supervision for five years and ordered to retake the state's test on legal and regulatory issues. He supervises five companies in the Houston area.
Donnie Evans, medical director for two EMS companies, was found in April to have written narcotic prescriptions for 15 patients without documenting properly the need for the drugs. He is under the supervision of another physician for the next three years. He says the medical board penalty does not tell the whole story.
"It had nothing to do with the lack of documentation. I was at a clinic that wasn't doing the right thing," Evans said. "So I didn't have the records to support what I did."
Evans says he gets paid between $500 and $1,000 a month by each one, but added, "Our roles are primarily perfunctory ... We review files. Not all the files, no."
Emmanuel Mbanefo Nwora, in June was ordered to attend a course on medical record-keeping and risk management and pay a $500 fine for not maintaining adequate medical records when he examined patients at a health fair at a retirement community. He has seven companies under his supervision.
Larry Lipscomb, who monitors five companies, has been sanctioned twice. In 2000, he was fined $2,000 for delegating medical duties to an unlicensed person. In 2003, he was ordered back to class for record-keeping and risk management courses.
Dudley Ross directs seven through his company, Qwest Inc. He was found to have submitted a falsified medical malpractice insurance certificate to his employer and was sanctioned by the state board and ordered to pay a fine.
"That issue with the board has been cleared," Ross said. "That (the sanction) had nothing to do with it (his EMS operation). That was totally separate."
Gibson, Mbanefo Nwora and Lipscomb did not return calls for comment.
Taken together, the companies these eight doctors now supervise have collected more than $45 million in Medicare dollars over the past five years.
Scott Rivenes, who operates Titus Medical Services, supervises more companies than any other doctor: 71. He has no disciplinary record and says he reviews run records every month. In the last five years, he has been hired by as many as 96 companies, which were paid at least $87.1 million by Medicare.
"Deviations are reported to me and feedback is given to the companies," said Rivenes, who also is an emergency room physician in Sugar Land. "As a taxpayer, I am of course worried about any fraudulently billed claim to Medicare, whether wheelchair, home health or unneeded EMS transport.
"If I become aware of any illegal activities, I would immediately terminate the relationship and turn over that information to the appropriate agency."