Perhaps no one was more relentless in his pursuit of Gross than Fred Moore, a special agent with the Defense Criminal Investigative Service. Part of Moore's job was to root out fraudulent claims processed by government health-insurance providers.
Every few months, Moore would show up at Gross' Fort Worth office, flash his badge, and demand to see the doctor immediately, even when he was in session with a patient. Then Moore would grill him about questionable billing practices.
How did Gross' name happen to appear on claim forms for patients who weren't his? How could he bill for services he claimed to provide on days he was out of town? Wasn't it true that he received kickbacks for committing his patients to certain hospitals?
Gross had answers for all of Moore's questions. His signatures on the claim forms were forged, Gross insisted, and when the agent questioned him about it another time, Gross even submitted to an FBI handwriting analysis. On the days he was away, therapists, other doctors, and medical students covered for him. And the substantial sums the hospitals paid him weren't kickbacks, but payment on his contracts with the hospitals that required him to do mental-health seminars.
Moore didn't buy Gross' explanations and told him so. In fact, he had no qualms telling Gross, as well as Gross' colleagues and staff he interviewed, that he thought the doctor was guilty of fraud and that he wasn't going to rest until Gross was behind bars.
In the spring of 1996, Moore looked like he was going to make good on that promise.
The U.S. attorney's office informed Gross they believed they had proof he bilked insurance companies by charging for services he did not perform. They wanted him to plead guilty to one count of fraud and spend two years in prison. They also asked him to wear a microphone to help them nab other unscrupulous physicians.
Gross refused, believing the case against him was bogus. The pressure began to mount. First, the IRS subpoenaed his business and tax records for the past six years. A few weeks later, Moore served him with his seventh subpoena in four years, the latest ordering him to produce records for every patient he treated--almost 700 files--plus correspondence with every insurance company he ever dealt with. He had three weeks to hand the documents over to a federal grand jury--a task that required him to photocopy all the files after carefully culling them for sensitive and privileged information. Gross was studying for law-school final exams at the time while still practicing psychiatry part time to support his wife and three children.
U.S. District Judge John McBryde refused to grant Gross an extension on the subpoena. Gross produced the documents five days late, but the U.S. attorney's office refused to accept them. McBryde found him guilty of criminal contempt, punishable by up to six months in jail and a $5,000 fine. A federal marshal escorted the doctor downstairs from McBryde's court to be photographed, fingerprinted, and jailed until he could post bond.
Special Agent Moore was waiting for Gross when he arrived at the booking area. He dismissed the marshal, saying he would take it from there. He ordered Gross to grip the cell bars while he frisked him for weapons while they were alone, which is against procedures. When Moore's hands got to Gross' genitals, the doctor says he cupped his testicles for longer than he should have and snickered. In a subsequent letter to federal officials, Gross likened the incident to a sexual assault.
That night, when Gross got home, he was crying and raving like a madman. Neither his wife nor his father, a former college professor visiting from England, could console him. After his encounter with Moore, Gross says, something snapped. He could no longer handle the pressure of the four-year intensive investigation and what he believed was the government's intention to get him by the balls any way it could.
It was then, he says, that he decided to flee. Two weeks later he disappeared.
For the last two years, fugitive Gross, as the federal prosecutors call him, has remained the lone holdout in a massive scandal that changed the way psychiatry is practiced. His is the final chapter of a story that rocked Texas, but his case raises as many questions about the prosecution as it does about the prosecuted. Is Gross guilty or simply guilty by association? A fish trying desperately to wiggle out of the net, or, as he insists, a decent man dirtied by a scandal that tarred an entire profession?
Gross' troubles stem from his four-year affiliation with the Psychiatric Institute of Fort Worth and Bedford Meadows Hospital. The two facilities were part of a national chain of mental-health hospitals owned by National Medical Enterprises, one of the worst offenders in psychiatric scandals of the early 1990s. In 1994, NME pleaded guilty in Washington to various fraud charges and paid a record $379 million in fines and restitution.
Gross is one of countless doctors embroiled in what some experts have labeled the biggest health-care swindle in history. In general, patients, many of whom were teenagers, claimed they were needlessly committed to long hospital stays tailored to match the amount of their insurance coverage. When their insurance dried up, they were pronounced cured and discharged. Many of the doctors, psychologists, and counselors affiliated with these hospitals were paid handsomely by the institutions to induce them to "put heads on the beds at any cost," as one hospital chain crudely described the corporate philosophy in a memo.
Gross is one of only a handful of doctors and hospital administrators whom federal prosecutors chose to pursue criminally. The majority of the criminal prosecutions have involved doctors and administrators employed by or affiliated with the Psychiatric Institute of Fort Worth. Paul Coggins, U.S. attorney for the Northern District of Texas, was helped considerably in this endeavor when former hospital chief administrator Peter Alexis agreed to cooperate with federal law enforcement officers.
In 1995, Alexis admitted to conspiring to defraud insurance companies of between $20 million and $40 million and paying doctors and therapists for patient referrals. He received a five-year probated sentence, plus a civil fine of $221,000, which he defrayed by relinquishing furs, artwork, and his Cartier watch collection. Alexis went on to profit from his crimes by offering useful information to plaintiffs who sued NME for abusive or unnecessary hospitalizations. Records show he earned more than $300,000 in his new line of work.
Described by federal officials as one of the most cooperative witnesses they ever worked with, Alexis helped federal prosecutors indict six area administrators and doctors on fraud charges. Five of them either pleaded guilty or were convicted and received substantial prison sentences, and hefty fines, and lost their licenses.
Gross is the only one who has yet to be tried--and not for want of trying.
Shortly after Gross fled to England, he was indicted in an alleged scheme to commit insurance and mail fraud by billing for services he did not perform and for accepting payment in exchange for keeping up a high hospital-patient census level. The exact amount of the fraud he allegedly committed is a bone of contention between Gross and the U.S. attorney's office and has become something of a dispute between U.S. officials and the British courts.
After 10 months on the lam, British police arrested Gross at London's Heathrow Airport in May 1997. A British magistrate ruled there was sufficient evidence to extradite Gross, who spent seven months in a maximum-security British prison while he appealed the decision. British authorities had denied bail because of the seriousness of his alleged crime; the U.S. attorney's office claimed on an arrest warrant that Gross had stolen $2.5 million from patients and insurance companies.
The magistrate's ruling was overturned on a technicality last June, but shortly afterward the magistrate once again ruled to extradite him. After reviewing Gross' indictment, however, the magistrate also determined that the evidence the U.S. attorney's office presented showed Gross' alleged fraud amounted to less than $5,000. This time British prosecutors did not refuse a bail request--practically unheard of in extradition cases. For the last nine months, Gross has been out of jail, helping his court-appointed attorneys prepare for his final extradition appeal hearing, which is scheduled to begin February 16.
Coggins' office claims that the amount of money Gross pilfered comes to just under a million dollars, when you combine the $800,000 the federal prosecutors say he accepted in kickbacks for patient referrals with the charges he billed six patients during two five-day periods he was out of town. The total amount of the fraud, they allege, could rise as high as $2.5 million.
An audit of the billings conducted by an accountant in the U.S. attorney's office puts the amount in question at $3,500--and several English High Court justices have concurred. Two British judges in written opinions have criticized Coggins' office for distorting the seriousness of the offense, and the case has led one international criminal-law expert to characterize the U.S. efforts against Gross as "anomalous."
"In my opinion, it is quite unusual for an extradition proceeding to proceed on the basis of a financial wrongdoing concerning such a relatively minor amount," reads an affidavit of M. Cherif Bassiouni, a De Paul University College of Law professor and author of a 1996 book on international extradition law. "Indeed, the very cost of these extradition proceedings will surely far exceed the amount of the alleged fraud."
The confusion stems from the fact that in an alleged scheme to defraud, the prosecution does not have to prove every instance of that fraud, explains a source in the U.S. attorney's office. The total amount of the theft is an issue for the judge to determine at sentencing. The $800,000 in alleged kickbacks was not a count on which Gross was indicted, but is mentioned in the preamble to the indictment so the prosecutors can introduce it at trial.
Over the phone from his home in Kent, a small town 30 minutes south of London, a dejected and depressed Gross insists he is innocent. He says he was an unwitting accomplice in the hospital's health-fraud scam and has been set up by former felonious colleagues who lied about him in order to reduce their prison sentences.
"I welcome an independent review of this case," Gross says. "I've done nothing wrong. I am tired of the lies the prosecution has spread about the case and about me." Gross is particularly sensitive to media reports that characterized him as having exchanged the Texas high life--where he drove a Lexus, wore a Rolex, and lived in an exclusive gated community in Colleyville--for an equally posh existence in England. Gross says that by the time he fled overseas, he was almost bankrupt, his psychiatric practice essentially ruined by the federal investigation. Extradition proceedings have prevented him from being hired in England. He has not worked in two years and is being supported by his father. He blames the U.S. attorney's exaggeration of his alleged crimes for imprisoning him for seven months in one of the toughest penitentiaries in England, where he spent 23 hours a day in a 6-foot-by-8-foot cell.
The prosecution's case, built on the affidavits of a handful of former patients, one former employee, and several former colleagues who are convicted felons, characterize Gross as a greedy doctor who didn't spend enough time with his patients. Several civil suits chastise him for using an experimental--and some say barbaric--treatment called rage-reduction therapy that traumatized rather than cured troubled teens. Another suit accuses Gross of inappropriately institutionalizing a 6-year-old girl for three months because he claimed she was suicidal and depressed over her parents' divorce.
But Gross has many defenders. Former patients have filled out sworn statements saying that he saved their lives, was always available to them, and never charged them inappropriately. Some, in fact, say he treated them for free on several occasions. Former colleagues and employees describe Gross as an exceptionally hard-working, compassionate doctor of the utmost integrity who spent more time with his patients than did most other doctors. They laud him for being willing to try new techniques on the most difficult adolescents.
This camp sees Gross as a victim of a witch-hunt. For four years, federal agents intensely investigated every facet of Gross' life. His supporters say investigators were hostile to any witness who was favorably disposed to the doctor and threatened to bring them before a grand jury if they spoke to him. Prosecutors hauled him in front of a grand jury five times, served him with seven subpoenas for documents, and charged him with criminal contempt for being late on one of them. They illegally searched his father's English home looking for the documents Gross had offered to turn over, and they indicted him only after he fled the country. After all this, all they could find was several thousand dollars in questionable billing, which they turned into a multimillion-dollar fraud indictment based on sworn statements from three convicted felons, one of whom also admitted to being addicted to drugs while working at PIFW.
"The most dangerous power of the prosecutor is that he will pick people he thinks he should get, rather than cases that need to be prosecuted," warned Justice Robert Jackson, U.S. attorney general under President Franklin Roosevelt, in a cautionary speech to U.S. attorneys in 1940. "...In such a case, it is not a question of discovering the commission of a crime and then looking for the man who has committed it. It is a question of picking the man and then searching the law books, or putting the investigators to work, to pin some offense on him."
"It's like using a sledgehammer to crush a mouse," says Gross' father, Jack, a 70-year-old former business professor from Philadelphia.
"It's a multimillion-dollar fraud as alleged in the indictment," counters Assistant U.S. Attorney David Jarvis, the lead prosecutor on the case. "Do you really believe if this was just a simple misunderstanding about billing, he would have fled prosecution?"
Jarvis has a point. If Gross had nothing to hide, why did he go into hiding? If the case against him is as flimsy as he maintains, why didn't he stay and fight? Jarvis will certainly introduce his fugitive status as evidence of his guilt.
Gross admits he made a terrible mistake by fleeing. "I didn't think there was a level playing field, and I still don't. If everything I am telling you is true, I still can't beat Jarvis. He has unlimited resources, and I am out of funds."
About the only thing in this case that is abundantly clear is that by becoming a fugitive, Gross weakened his position considerably and hurt his family, who joined him in England a few months after his arrival there, immeasurably. He became a man without a country, a doctor without a profession. And if federal prosecutors have their way, the 41-year-old father of three and once-promising child psychiatrist most certainly will be a man without freedom--possibly for as long as 40 years.
In the mid-1980s, the Texas Legislature sowed the seeds of the scandal that ensnared Robert Gross and countless other doctors when it allowed a provision of a state statute that regulated the number of hospital beds in the state to lapse. Chain hospitals, particularly in the psychiatric field, moved into Texas with a vengeance, which resulted in an oversupply of hospital beds and fierce competition for patients to fill them.
The insurance industry initially welcomed the increased competition, assuming the law of supply and demand would increase the quality of service while driving down costs. In fact, the opposite occurred. The psychiatric-care industry became big business, and costs continued to skyrocket. The chain hospitals were run by businessmen, not doctors, who arrived in town with high-pressure marketing strategies and slick and deceptive advertising campaigns, many of which played on parents' fears of the growing rate of adolescent drug abuse and suicide.
These chains had attractive incentive programs--free office space, lucrative contracts for staff positions--designed to lure doctors.
Doctors like Robert Gross, for instance. A native New Yorker and graduate of the University of Rochester, Gross says he knew from an early age that he wanted to be a doctor. He attended the University of Texas Medical School at Galveston.
Gross did his residency at the University of Texas Health Science Center in San Antonio. He spent two years in his psychiatry residency, then went on to receive a fellowship in child psychiatry, which required an additional three years of study. The extra effort paid off and made him more marketable, as child psychiatrists are fairly rare. In 1988, Gross saw an ad in Psychiatric News, an industry newspaper, for Psychiatric Institutes of America, which was looking for doctors to serve hospitals in Longview and Fort Worth. Gross answered the ad.
Peter Alexis flew to San Antonio to wine and dine Gross and his wife. He was accompanied by Burleson therapist Bert Wayne Bolan, who ran a mental-health clinic that frequently referred patients to PIFW, and Fort Worth psychiatrist Hernan Burgos, who recently had become the hospital's medical director. Bolan and Burgos eventually were convicted of fraud and sentenced to eight and five years in prison respectively, Bolan for accepting approximately $5 million for referring patients to PIFW, and Burgos for filing more than $1 million in fraudulent insurance claims.
The charismatic, high-energy Alexis, a former Chicago sportswriter, and Gross, an avid sports fan, hit it off immediately. Alexis offered Gross a $250,000 one-year contract that paid him to be the director of the adolescent-treatment unit and provided him $20,000 a month in salary until his practice was up and running. Once he started developing a referral base and began making money on his own, Gross says, the contract required that he pay PIFW back the money for the salary, which he claims he did.
Gross built his practice quickly, thanks to a PIFW director who helped introduce him to the Tarrant County medical and mental-health community. Only psychiatrists could admit patients to a hospital, and if a counselor felt one of his patients should be committed to PIFW, the hospital frequently referred those patients to Gross. Gross also received many referrals from Wayne Bolan, the therapist who ran the Center for Human Growth in Burleson. Gross says he would frequently return the favor to Bolan, referring patients who needed a therapist either during hospitalization or afterward.
After Gross' year contract with PIFW was up, he signed another contract with the hospital and its affiliate in the mid-cities, Bedford Meadows. This $250,000-a-year, five-year contract made Gross the medical coordinator for community education for the two hospitals and required him to do speaking engagements in the Dallas/Fort Worth area and teach hospital staff about new therapies and drug regimens. He also supervised medical students from the Texas College of Osteopathic Medicine in Fort Worth, who accompanied him on rounds in the morning and provided therapy to patients in the afternoons.
By all accounts, Gross fulfilled the terms of the contract. He hired Marilyn Schiffman, an Arlington marketing consultant, who booked him into an almost weekly schedule of one- to three-hour seminars at elementary schools, Rotary clubs, and medical centers.
"My impression was that the guy was a real workaholic, " Schiffman recalls.
According to affidavits by Alexis and Bolan, Gross' hospital contracts were shams. They claim that Gross knew he was never required to fulfill the terms of the contracts and that their only purpose was to induce Gross to admit as many patients as he could to PIFW and keep them there as long as possible.
"Their affidavits are crap," Gross says. "If they were sham contracts and I didn't have to do the work, why was I working so hard?"
Copies of monthly reports he says he was required to submit to PIFW show that he spent anywhere from three to 10 hours a week on community education activities. Assistant U.S. Attorney Jarvis will no doubt try to show that Gross did not do enough work to justify $250,000 a year and that the money was a bounty for hospitalizing patients, which is a violation of medical ethics as well as the Medicare anti-kickback law.
To Louis McBee, the government's case against Robert Gross smacks of selective prosecution. Owner of a well-established medical billing and physician-management company in Fort Worth, McBee says that Gross' contracts were not much different from contracts many county hospitals have with physicians who work on the premises and also bill for the patients they serve.
A prominent Dallas psychiatrist formerly affiliated with Timberlawn Psychiatric Hospital in East Dallas agrees. The doctor, who asked for anonymity, says, "When the psychiatric hospital scandal started surfacing in the early 1990s, practice-guaranteed or professional service contracts were suddenly brought under scrutiny and arbitrarily categorized as constituting bribery for referrals," the doctor says. "In recent years, it seems that government and insurance-industry investigators have retroactively applied 1994 rules and ethical standards to what were common and accepted practices in 1988...It also seems as if a double standard has been applied to the psychiatric profession. For instance, other physicians still routinely accept such things as all-expense paid trips from drug manufacturers, and this is not viewed as a conflict of interest or bribery when those doctors prescribe the company's product over another's."
Gross insists he never indiscriminately institutionalized patients and never kept them longer than he thought medically necessary. Former employees of PIFW, which closed its doors in 1993, and therapists who worked closely with Gross back him up. Danny Campsey, a licensed vocational nurse who worked at PIFW from 1987 to 1992, said he had great respect for Gross in terms of his professional ethics, according to a 1995 interview he gave a private detective who worked for one of Gross' lawyers.
"He recalled one particular incident in either 1989 or 1990, which vividly demonstrated to him that Gross placed the interests of his patients first," the investigator wrote. "One afternoon, Campsey overheard a conversation at the nurse's station between Gross and the pre-adolescent unit director...[who] was clearly trying her best to convince Gross to postpone the discharge of one of his patients, which he had ordered for the next day. Campsey heard the [director] say that she strongly disagreed with the discharge, that more time was needed for treatment closure, and that there was still insurance money to keep the patient for at least several more days.
"Gross responded that he felt the patient was ready to be returned to the family environment, that nothing more could be accomplished in the hospital setting, and that he intended to discharge the patient as scheduled the following morning regardless of [the director's] objections. At one point the conversation between the two became quite heated, and voices were raised. Campsey noted that throughout the discussion...Gross remained adamant that the patient would not be kept one day longer than he felt necessary."
Out of the 700 patients Gross says he treated in the seven years he practiced psychiatry, only one person filed a suit accusing Gross of unnecessarily hospitalizing a patient. The case involved a 6-year-old girl whom Gross admitted to PIFW for three months in November 1990 after diagnosing her with depression. The girl was referred to Gross by a therapist in Wayne Bolan's Center for Human Growth, who had treated the girl for several months and claimed the girl had told her repeatedly that she wanted to hurt herself because she was distraught over her parents' divorce. The girl's mother reported that several times she had to stop her from running into traffic.
The girl's father went to court in Fort Worth to get her released. The judge ordered that she be evaluated by another psychiatrist, who concurred with Gross' diagnosis. The father turned to the Johnson County courts, which ordered another evaluation of the girl by a psychiatrist and psychologist in Dallas, who concluded that the hospitalization was inappropriate. The judge ordered her released.
According to the affidavit of the nurse who had the most contact with the girl during her stay at PIFW, the girl's hospitalization was "justified and necessary, at least within the context of what was common and accepted practice during those years."
"I don't diagnose lightly," says Gross. "I don't like labeling a child. The girl's mother, who had custody at the time, approved the commitment and was free to take her out anytime."
A respected psychiatrist affiliated with Green Oaks Psychiatric Hospital in North Dallas admits that all doctors probably hospitalized patients too long in the late 1980s and early 1990s. But greed was not always the motivating factor, says the doctor, who asked that his name not be used because he did not want to invite scrutiny from federal officials.
"It seems naive now, but we really thought patients would do better and deal with their issues if they were in a more intensive setting. We really thought it was better treatment. The idea was to fix people rather than patch people. Now it is all crisis intervention and outpatient treatment. With managed care, you can't get reimbursement for hospitalization. The criteria for what is medically necessary is so rigid."
Gross' association with Wayne Bolan and his Center for Human Growth first brought him to the attention of federal investigators. In the summer of 1991, the Civilian Health and Medical Programs of Uniformed Services (CHAMPUS) contacted Gross to ask for money back on claim forms that he had signed, but that had improper documentation. Gross had never heard of the patients and had not received the insurance money--approximately $1,200 for 25 outpatient therapy sessions.
Gross and his attorney flew to CHAMPUS headquarters in Colorado to straighten out the matter. He discovered that his name had been forged on the claims forms. The patients were Bolan's, and his office had received the funds. CHAMPUS believed Gross and did not hold him responsible for the billings.
When Gross returned to Texas he phoned Bolan for an explanation, Gross says. Bolan apologized and said it had been a mistake and wouldn't happen again. Five years later while sitting in prison, Bolan signed an incriminating affidavit used in Gross' extradition proceedings that claimed, among other things, that Gross had allowed his office to forge his signature. This scheme allowed Bolan, who had a Ph.D. in health education but was not a physician, to get money from insurance companies that only covered sessions by therapists who were licensed doctors or who were supervised by one.
Gross and Bolan frequently referred patients to one another, and Gross says he did co-sign claim forms for Bolan, but only for those patients whose care Gross supervised for Bolan. After Gross confronted Bolan about the forgeries, Gross says, he distanced himself from the therapist.
"Why would I risk my medical license by allowing someone to forge my name?" Gross says. "And I was the one who alerted CHAMPUS that these were forgeries."
Bolan makes other accusations in the affidavit that undermine his credibility. He claims that Gross knew his contracts with PIFW were shams, because Bolan was at Gross' recruitment dinner in San Antonio when Alexis told him the contract was a "sweetheart deal," conditional on Gross' willingness to admit patients.
"Do you really believe that these people would tell someone they were meeting for the first time that they were stealing money?" Gross says. "I could have been an FBI agent for all they knew."
Marvin Burns is a licensed professional counselor who was employed for several years at the Center for Human Growth and worked closely with Gross. Burns says Gross' approach to patient care could not have been any more different from the center's.
"The emphasis at the Center for Human Growth was on hospitalization rather than on treating," says Burns, who had previously worked for Johnson County Mental Health/Mental Retardation. "There was so much pressure on me to get people to agree to be hospitalized that I resigned."
Gross was one of the doctors whom Burns, a certified play therapist, worked most closely with, because they both specialized in counseling children. "Dr. Gross was well known for his work with children, and he was the doctor I relied on most...I trusted him implicitly," he says.
"From my limited perspective, in that whole crazy system, Dr. Gross was the only child psychiatrist I really felt comfortable with. He never hospitalized a patient unnecessarily, and if I thought a patient needed to be discharged, I never got pressure from him to keep them in. I would get angry calls from PI administrators or Bolan when I wanted to discharge a patient."
Gross' approach also differed from that of Dr. Hernan Burgos, a former co-owner with Bolan of the Center for Human Growth, who received a five-year sentence for insurance fraud. "Burgos would hospitalize a patient longer than they needed to be," says Burns. "He would order unnecessary tests. I saw him violate so many things."
Burns told all of this to federal agents who interviewed him in the mid-1990s. Fred Moore, who threatened to investigate Burns if he refused to talk, didn't like what Burns had to say. Moore told him Gross had been paid for every patient he committed to the hospital and was billing for up to 100 patients a day.
"I told him that the Dr. Gross I knew didn't fit that description," Burns says.
Nor did it fit the description of the man Mary Ann Lawrence knew. Gross' office manager between March 1992 and February 1993, Lawrence says that when she was questioned by government lawyer Jarvis, "my impression was that Mr. Jarvis was not interested in any information I had that might tend to vindicate Dr. Gross." In fact, she says Jarvis had to rewrite her affidavit three times before she would agree to sign it because it misstated her testimony.
Lawrence's experiences with agent Moore were just as unsettling, she says. Moore told Lawrence and her husband, a Dallas police officer, that he "knew Gross was guilty and was going to get him one way or another." At that point, Lawrence's husband asked Moore to leave his house.
"That man is out for blood, and he doesn't care whose blood it is," Lawrence's husband told her.
For his part, Moore says he cannot comment on the Gross case, because it is still under way. But he says he is aware of the criticisms Gross and his father have about the way he conducted his investigation. "I am supposed to be rude, crude, and socially unacceptable," says Moore from his Fort Worth office. "But you can't believe everything you read in newspapers or in what they filed."
There is no question that Robert Gross had a busy practice; his detractors say too busy. At times he had as many as 30 patients in the hospital, although his average caseload was lower. Brenda Prellwitz, a former office manager for Gross, told federal officials that Gross had far more patients than he could possibly see in a day.
Gross says the size of his caseload is misleading, because not all his patients required daily visits. Contrary to the popular conception of a psychiatrist doing 50-minute therapy sessions with patients, Gross' role--and that of most psychiatrists in a hospital setting--was to be more of a treatment leader. He assessed the patients, took their history, made the diagnosis, and prescribed a drug regimen, if needed. Patients' days were filled with group and individual counseling from others.
During rounds, Gross says, he checked every patient's chart, talked to nurses, and visited with each patient to find out how they were doing. If they needed more of his time, he frequently returned at night. Many patients also called him at home to talk. He says he charged about $150 for rounds and $200 if he also talked with family members and met with members of the treatment team.
Affidavits from five nurses who worked with Gross at PIFW--none of whom were interviewed by federal investigators--are highly complimentary of the doctor, who, said one nurse, "did not admit his patients and forget about them, unlike some doctors."
Gross claims he actually billed less than what he was entitled to. He says he could have charged patients again if he saw them more than once a day or for every time they called him on the phone, but didn't think that was fair. In addition, insurance rarely reimbursed him for more than 50 percent of his services, and he says he never refused to treat someone who couldn't pay.
Bobbie Badger, one of Gross' former outpatients, concurs. "When I first went to see Dr. Gross, we thought insurance would cover it, but he wasn't on their preferred provider list and [they] refused to pay," says Badger, a Colleyville piano teacher who saw Gross for six months because she thought she suffered from attention deficit disorder. "He told me not to worry about it. I would send him $25 or $50 a month. I still owe him several hundred dollars, but he won't let me pay. If he were still here, I would go back to him in a heartbeat."
During their investigation, Jarvis and Special Agent Moore talked to Jan Kavanagh, Gross' office manager for the first two and a half years he was in practice. They asked Kavanagh if she was worried that Gross was too busy to care for all of his patients.
Kavanagh was concerned, she admitted, but not about the patients. "I was concerned that he was working too hard," she says.
Kavanagh told Gross' investigators that Jarvis ordered her not to discuss the Gross matter with anyone without first informing him and obtaining his approval. The government lawyer kept questioning Kavanagh "to the point of harassment" about whether Gross had enough time to administer therapy to his patients. She told Jarvis that she suffered from multiple sclerosis, which was affecting her memory. Jarvis facetiously asked her if her memory problem was "'long-term, short-term, or selective.'"
Clearly, Gross has several young patients who thought they had received entirely too much therapy from the doctor. As the federal investigation into Gross' relationship with PIFW and billing practices dragged on for years, he was also fighting several malpractice lawsuits filed by former teenage patients who accused him of assault and battery and intentional infliction of emotional distress. The allegations stemmed from his use of a controversial technique known alternately as rage reduction, trust development, or holding therapy.
At first blush, rage-reduction therapy seems to be just another in a long line of weird experimental treatments whose benefits were questionable. Developed by prominent Colorado psychiatrist Foster Cline, rage reduction was aimed at helping particularly troubled, frequently violent children and adolescents who suffered from attachment disorder--the inability to form emotional bonds with, and feel empathy for, others. Many of these youngsters had been victims of abuse, and more conventional therapeutic treatments had not worked with them.
The purpose was to create a controlled setting and provoke the children, who could only express their anger in inappropriate ways. Always done in the presence of a parent, who had to sign a consent form after being informed of what the process entailed, four hospital workers would hold the patient down and the doctor would poke or tickle him in the rib cage to incite cathartic rage.
The sessions end with the emotionally spent patient in the protective embrace of the parent.
Gross will be the first one to say that when he first learned about rage-reduction therapy, he thought it sounded barbaric. "I was always aware that this was not normal therapy," says Gross. "But when I saw the results it had, I thought it would be worthwhile treatment."
In 1989, 15-year-old Jeannie Warren underwent rage-reduction therapy with Gross. Four years later, Warren sued Gross, accusing him of physically and emotionally abusing her. Newspaper stories about the case describe Warren as a rebellious teen whose adoptive mother hospitalized her because of a deep-seated resentment of her biological mother. But Gross says that is not the whole story. Warren's early years were traumatic and included watching her biological mother shoot her father. She was hospitalized after she sexually abused one adoptive brother, went after another with a hatchet, and carved on her forehead.
"All other treatments had failed her," Gross says. "This was a last-ditch effort, and I think I really helped her."
A judge saw it differently. He awarded Warren $8 million in damages during a hearing held after Gross had fled to England.
The Texas State Senate's Health and Human Services Committee held hearings on rage therapy in the early 1990s and created the Treatment Methods Advisory Committee to investigate further. The advisory committee expressed concern about "extreme cases of provocation" but ultimately decided against taking a position on the treatment.
His detractors and defenders aside, the federal case against Robert Hadley Gross ultimately will come down to whether his patients received all the treatment for which he billed them. The heart of the indictment against Gross concerns six patients who received charges for Gross' services totaling $3,500 for two five-day periods when he was out of town in 1991. In March of that year, he attended a psychiatric conference at Harvard and in August took a family vacation to Padre Island.
The indictment alleges that Gross "falsely claimed that he had personally provided psychiatric care to these patients when he was out of town." That is, in fact, false. Nowhere on the claim forms, or on any of the 600 pages of documents the U.S. attorney sent to England for the extradition proceedings, does Gross ever claim to have provided those services himself. Nor do the claim forms say that he has to. At the time, Medicare, CHAMPUS, and Aetna--the health-benefits provider for these six patients--permitted physicians to bill for services provided by others in their absence and charge his own going rate.
When he went on these trips, Gross says, he arranged for several physicians to be on call for him in the case of emergencies or if the patients needed medical orders called in. He had the medical students who were on his rotation at the time do his rounds in the morning and return in the afternoon to do therapy if needed. And he asked the patients' therapists to schedule an additional session or two in his absence. The therapists who saw these six particular patients billed for their services through Gross, who paid them back once insurance paid him.
According to the U.S. attorney's own assessment of the patients' charts, medical students and on-call physicians did see the patients, and Gross signed off on the students' notes when he returned. There is no mention of individual therapists seeing the patients, however, but Gross says he is not sure the U.S. attorney's office looked at the part of the patient chart where that would have been recorded.
The one area where experts say Gross may be on shaky ground was in his use of third-year medical students to fill in for him in his absence. Medical students are not yet licensed and have only a modicum of training in the subject of their rotation. In the last few years, the federal government has begun cracking down on attending physicians or hospitals who bill Medicare for work done by interns, residents, and medical students.
A.W. DeLorenzo, a former medical student at the Texas College of Osteopathic Medicine, was one of the students who looked after Gross' patients in his absence. "I don't think it was right, and I don't think anyone else does," says DeLorenzo, who practices internal medicine in Illinois today.
Gross says he had the medical students do rounds because they were more familiar with the patients than an on-call physician would have been. "I'm not talking about diagnosing heart attacks here," Gross says defensively, adding that experienced physicians were on call if needed. "The patients were already in therapy with medical students. They knew the issues that needed going over during rounds. They had rounded with me in the morning and had individual therapy with them in the afternoon. It was a teaching hospital. That's what medical students did. We went over what they did when I came back, and I signed the students' progress notes."
Gross points to laws and regulations that he believes gave him the authority to give so much responsibility to medical students while he was away and bill for it. The Health Care Financing Administration insurance form, which is used to process assorted government health-care insurance programs, allows physicians to bill for a service provided by someone else, but the service "must be rendered under the physician's immediate supervision."
According to a recent American Medical Association's Physician Guide to Medicare, "HCFA guidelines state that patient contact is not required of the physician on each occasion that a nonphysician employee provides a service...[T]he requirement would be met if the physician initiates the course of treatment and provides subsequent services that reflect his or her active participation in managing the patient's treatment."
Gross says that if he interpreted the regulations too liberally, it was an honest mistake. He never did so to intentionally defraud anyone. "For the government to make a fraud case against me, they have to prove intent," Gross says.
Sources in the U.S. attorney's office say Gross is fooling only himself with this rationale. They say attending physicians must be immediately available to supervise medical students. Furthermore, they believe they can prove that Gross also billed for therapy that was never performed.
Included in the extradition papers sent to England are identically worded affidavits from these six patients, who claim Gross saw them only about half of the times he billed for. Gross questions the validity of the affidavits, which required children who had been hospitalized with mental-health problems to remember with accuracy events that happened to them six years earlier, when some of them were as young as 7.
Gross believes the hospital records, which federal officials have repeatedly denied him, will ultimately vindicate him, with the help of recollections from more credible patients. Take Pat G., for instance. A 27-year-old defense-industry employee hospitalized for depression about the same time as the six patients mentioned in the indictment, Pat G. gave Gross' investigators the following sworn statement:
"During the first month of my hospital stay, Gross visited me once a day, Monday through Friday. He saw me both in group and in individual sessions, with the latter lasting between 30 and 45 minutes. If I ever needed Gross on weekends, he was always available...I credit Gross and his care with my turnaround. In my opinion, Gross saved my life...I told [federal] investigators that I always checked my monthly billing from Gross and never found incorrect charges..."
Pat G. was upset about one thing, however--that federal investigators had her confidential files and were using the information to question her.
The psychiatric scandals of the early 1990s had a chilling effect on the entire mental-health field. The intensive inquiries and subsequent changes made needed improvements. Other changes were overkill and caused some doctors to refuse to do any work with hospitalized patients.
Other doctors, like Gross, thought about leaving psychiatry altogether.
By 1994, the federal investigation into his practice had made it difficult for him to continue in the field. He also says he was somewhat bored with doing strictly outpatient work. PIFW and Bedford Meadows had canceled his five-year contract to do community education in August 1991, when the hospitals started to come under scrutiny. Gross sued NME for breach of contract and subsequently lost his admitting privileges.
In 1994, after spending so much time in lawyers' offices, he decided to go to law school while still maintaining a limited outpatient practice. He attended Texas Wesleyan University School of Law in Fort Worth, where he made law review. He was six months away from graduating when he became a fugitive.
"I've thought a lot about my decision to leave," he said in a recent phone call from his home in England. "I regret it now. I'm sorry I left, but I wasn't thinking straight. I put my family through a lot of pain I shouldn't have."
Last fall, Gross sent U.S. Attorney Paul Coggins a letter attacking the fairness and integrity of his office's investigation and explaining in detail why he believes he is innocent. In a letter to Gross' barrister, Coggins replied: "The proper forum to address any concerns relevant to the pending indictment is during a trial before the United States Court for the Northern District of Texas. I urge fugitive Gross to return to the United States as soon as possible so that the validity of his claims may be evaluated before the proper tribunal."
Gross fully expects that will happen. He does not think he will win his extradition appeal, which will be heard by the British High Court--the English equivalent of the U.S. circuit court of appeals--next week. If the justices rule that he should be extradited, the British home secretary then decides whether to surrender him to the American authorities. Gross can make a last-ditch appeal to the European Court of Human Rights.
Jarvis recently offered him a plea agreement asking him to plead guilty to one count of fraud worth $750, which is punishable for up to five years in prison and a $250,000 fine. He would also be required to surrender his medical license. But Jarvis also wanted to reserve the right to introduce the alleged "sham" contracts during sentencing, no doubt in the hopes of getting a maximum sentence.
Gross refused the deal. "Why should I plead guilty to something I didn't do?" In a letter to Coggins, he offered a counterproposal in which he says he was willing to pay back the $3,500 in questionable billings and a moderate fine. He does not want to surrender his medical license.
"It's difficult just revisiting all of this," Gross said, after he began recounting the ordeal of the last 10 years. "I've never gotten over the sudden change. One minute I'm in Texas with a job and friends and going to law school. Now, every part of my life has been uprooted. I still feel like it's a nightmare, that I'm going to wake up and it's going to be back the way it was. But I know better than anyone that's never going to happen.
