On Nov. 22, 2013, a press release from the U.S. Attorney for the Middle District of Tennessee announced the office's latest catch.
"Prominent Nashville Pediatrician and Former Owner of Centennial Pediatrics Pleads Guilty to Health Care Fraud," blared the headline quickly scooped up by local media outlets. Dr. Eddie Hamilton, the release said, had pleaded guilty in U.S. District Court to a misdemeanor count of health care fraud. As a part of his plea, he would be excluded from participation in all federal health care programs for 20 years, pay criminal restitution and damages of $1.6 million, and sell the practice he had built over the past two decades.
Prosecutors, like fisherman, are wont to highlight the size of their hauls. But that's not to say Hamilton wasn't a big fish. Since founding Centennial Pediatrics in 1990, he had built it into one of the largest pediatric providers in the state focused on serving the underserved. At its peak, Centennial had 50 providers serving 80,000 children, and brought in $20 million a year.
But the release didn't mention some other facts that might put the Bad Doctor in a different light, or at least a more complicated one. Like the fact that his alleged upcoding resulted in overbilling of a mere $280,000 over a six-year period — not an insignificant amount of money, but nowhere near the totals found in some other cases.
Hamilton's personal credentials are worth noting, too. He was the first black resident to finish the pediatrics program at Vanderbilt University Medical School; he was the medical director for the Children's Hospital at Centennial for its first year; and he serves on the board of directors for the Martha O'Bryan Center and the board of trustees for the University School of Nashville.
Sitting in his Midtown office off Charlotte Avenue, he believes his punishment hasn't fit his crime — particularly because the punishment keeps coming. On July 22, Hamilton will go before the state Board of Medical Examiners, which is seeking to suspend his license for a year — a move Hamilton says would effectively kill the small practice he's put together since being forced out of his first. In his telling, Hamilton is like a man in quicksand whose every attempt to climb out only causes him to sink further.
His crime — a word Hamilton still uses with scare quotes — stemmed from two codes his practice used to bill for infant auditory screening exams and urinalysis. Parsing the details of the medical procedures gets more complicated, but the gist is this: While the government ultimately accused Hamilton of billing for procedures he wasn't performing, he maintains that his practice used the codes that best reflected the service they were providing.
In one case, he says, the discrepancy arose from outdated terminology. For instance, while the government accused him of billing for microscopic urinalysis without using microscopes, Hamilton says new machines test for the same things doctors used to look for under a microscope. The discrepancy, he claims, was not in the care provided, but in the terminology used to describe it. The federal government disagreed.
When it became clear that his arguments for both codes were not getting anywhere, he says, he decided that it wasn't worth a protracted legal fight. Instead, he says, he offered to simply pay back the $280,000 in overbilling, along with a fine. Looking around at the civil settlements that often occur in the industry, he assumed that would satisfy the government and put the situation behind him.
It did not.
"That's when it became clear to us: They want more out of this then just us to use the right code in their mind," he says.
He was right. In April 2014, The Tennessean reported on the government's increasingly aggressive pursuit of health care fraud.
"The government has real financial incentives for chasing down cases it looks likely to win — for every dollar spent on a health care fraud and abuse investigation, the HHS says it recovers $8.01," the daily's Shelly DuBois wrote.
There are also incentives for whistleblowers, who receive a percentage of the money recovered by the government as a result of the information they provide.
Still, Hamilton says he was caught off guard when he learned the government was coming after him criminally. During his recent interview with the Scene, he offered a stack of news stories and press releases detailing similar cases where health care providers paid much larger fines to cover bigger losses, yet faced no criminal charges and went on practicing medicine.
A recent example is CareAll, the Nashville-based home health care provider. In November, it paid $25 million to settle claims it had overbilled the government. Just two years earlier, CareAll had paid $9.4 million to settle similar claims, in a settlement that allowed the practice to continue working with Medicaid.
There are indeed examples of health care fraud cases that have led to criminal charges, but settlements like CareAll's have Hamilton feeling singled out for unusual treatment. Lisa Rivera, the former federal prosecutor who worked on Hamilton's case, declined to comment for this story.
Soon Hamilton was being offered a deal that would have him pleading to a felony, a deal he says he simply couldn't accept. Not just because of what it would mean for his career, he says, but also because of what it would mean for him as a black man in America. Ultimately, he agreed to plead guilty to a misdemeanor, with all the aforementioned stipulations — that he would pay a $1.6 million fine, sell his practice, and stop participating in federal health care programs for 20 years.
But again, what he thought was solid ground turned out to be a trap door. He intended to continue serving commercially insured patients, and believed his plea agreement would allow him to do so. It turned out, however, that agreeing to be excluded from Medicaid and Medicare — as opposed to voluntarily withdrawing and re-applying later — triggered policies at hospitals and insurance companies that brought an unexpected consequence. He learned that he would be prevented from having any hospital privileges or accepting any private insurance.
This wasn't just news to Hamilton, as a transcript of his February 2014 sentencing hearing shows. As he explains to the court the implications of the plea, U.S. District Judge Aleta Trauger expresses her surprise.
"So it sounds like there are more severe collateral consequences than were initially envisioned," she says.
The transcript also reveals some further insult added to injury, which he can almost laugh about now: Although he was indicted as Edward D. Hamilton, he has never been an "Edward." His driver's license reads "Eddie," he says, as does his birth certificate.
More important to determining his identity are other comments deeper in the transcript. While Trauger says "there is no way this was not a criminal offense that should have been prosecuted," citing evidence that Hamilton had been told by others in the field that he was using the wrong codes, she also goes on to praise him as a figure in the community.
"Dr. Hamilton is an extremely impressive individual," she says. "The letters — I probably have never received such an abundance of high praise for anyone that I have sentenced."
Later she adds "I do hope that Dr. Hamilton is able to continue to practice."
For a time, it looked as if he might. He started a new practice, Icon Pediatrics, using a concierge model where he doesn't accept any insurance. Outside of his growing patient base, he assisted five charter schools last year by volunteering to provide the legally required individualized health care plans for 150 children with chronic illnesses. He was set to do the same for three more schools this coming year.
All of that will crumble, he says, if the state board suspends his license next week.
Asked if he pissed someone off, he and his wife Arnetta muster a chuckle. That's what everyone asks, they say.
Outside of a legal dispute with some former associates, he says nothing comes to mind. But he has caught wind and innuendo that suggests to him that someone — some people? — resent the flashy wealth he had achieved over the years. He and his family had a nice home in Hill Place and he drove a Maserati. He says he wonders if the real resentment comes from the fact that, although the Hamiltons have spent millions in legal fees and had to borrow money from their parents, they still live in the same house, and his kids still go to the same private school. And although he drives a different car, it's a Mercedes.
"It's kind of like, why it keeps on, is because I didn't cave in, I didn't die, I wasn't utterly destroyed," he says.
He can't prove it, he concedes, but he says the way this just won't end has given him and his wife plenty of fuel for paranoia. And the fuel keeps coming. Not long ago he received a call from the state attorney general about a supposed conflict of interest related to a nonprofit he started; a sponsorship of a Little League baseball team in Brentwood was derailed when someone went to the league's board to warn them of Hamilton's conviction.
"It's day in and day out, constant conversation about people harming us," Arnetta Hamilton says after her husband recalls the whole years-long tale. "All we want to do is move on. We want to be left alone. And if it's race, come out and say it. But don't continue to harm the need of children and all that he has done for this community. No one can take his place.
"This is a game for someone," she adds.
State Department of Health spokesman Woody McMillan declined to comment on the pending proceeding. So for now, it's not clear why the state wants to suspend Hamilton's medical license on top of the punishment he's already taken — especially when larger offenders have continued to practice after paying their fines.
"There's no need to take my license from me," Hamilton says. "What are you accomplishing by doing that? It's making absolutely no sense. So that's part of why I say, 'Well, we gotta fight it.' I didn't fight it the first time because I thought I was protecting the practice and my family by entering this plea and not knowing that in spite of falling on my sword, so to speak, these things still happened."
Next week, Hamilton plans to reject the board's offer to accept a one-year suspension of his license, choosing instead to enter into a contested hearing. He has already been told that if he fights the board, and is unsuccessful, the resulting punishment could be even worse. But at this point, that'd be nothing new.
