PAULA A RODRIGUEZ

NPI 1841543766, individual, Guayama, PR, Occupational Therapist

Evidence tier

structure or single-organization volume

Hours beyond a day in 2 months under one organization, which can be supervisory billing.
Records needed.
Medicaid dollars per patient on code 97112 ($235 per patient-month) sit in the top 5% of every provider billing that code.

score 55 of 100, rank 7925, $537K at stake

Hours billed per day

Medicaid billing converted into hours of hands-on care per day. The lower bound counts one unit per claim line and needs no price; the other two divide dollars by a unit price, the conservative one at 1.5 times the price. The clinician on the claim may be a supervisor under state rules, so billing organizations are counted too.

month	what was found	hours per day, lower bound	hours per day, at price	hours per day, conservative	per working day	patients	billing organizations	codes	paid
Oct 2024	More hours than a day holds, even counting one unit per claim line	64.7	24.3	16.2	14.5	287	1	97110 97112 97530	$92K
Nov 2024	More hours than a day holds, even counting one unit per claim line	56.9	67.0	44.7	36.2	279	1	97110 97112 97530	$224K

National provider registry

From the CMS NPPES Registry, refreshed daily.

Name	PAULA A RODRIGUEZ
Type	Individual
Status	Active
NPI issued	October 16, 2012, last updated July 22, 2022
Practice location	B26 CALLE 4, URB. VILLA ROSA 1, Guayama, PR 00784, 787-557-2127
Specialties	Occupational Therapist (225X00000X, primary, license 1011 PR)

Procedures billed

The specific codes behind the dollars. Medicaid figures come from T-MSIS (2018 to 2024) and are compared with every other provider billing the same code; Medicare figures come from the 2024 physician and supplier file and compare this provider's submitted charge with what Medicare allowed, against the usual ratio for that code.

Medicaid, largest codes

code	what it is	paid	share	per patient-month	typical	rank among providers
97112	Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes	$461K	41%	$235	$59 (top 5% from $187)	97th percentile
97110	Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes	$402K	36%	$205	$76 (top 5% from $314)	87th percentile
97530	Therapy procedure using functional activities	$250K	22%	$770	$124 (top 5% from $387)	100th percentile
97166	Evaluation for occupational therapy, typically 45 minutes	$6K	1%	$97	$53 (top 5% from $238)	too few months to rank

In this area

81 providers in PR carry an indicator in the public record, with $52.2M at stake between them. The most common is more hours than a day holds, on 70 of them, followed by part of a provider network on 5. 6 are tier 1: documented action, then payment.

tier	provider	at stake	why
1	MELVIN MATHEWS BERMUDEZ Manati, PR, ranked 119	$166K	Listed on the Medicare revocation list since January 22, 2020. Medicaid still paid claims in 32 later months, $165,501 in total.
1	PHYSICIAN H.M.O. INC. San Juan, PR, ranked 158	$81K	Adjudicated (pleaded guilty) per a Department of Justice release dated July 17, 2025. Medicaid paid $81,097 in the last 12 observed months.
1	DIANA GALLARDO Caguas, PR, ranked 321	$5K	Listed on the OIG exclusion list and the Medicare revocation list since July 9, 2021. Medicaid still paid claims in 8 later months, $5,215 in total.
1	VILLALBA MEDICAL TRANSPORT LLC Juana Diaz, PR, ranked 401	$909	Listed on the Medicare revocation list since November 2, 2023. Medicaid still paid claims in 1 later month, $909 in total.
1	PHYSICIAN HMO INC. San Juan, PR, ranked 408	$680	Adjudicated (pleaded guilty) per a Department of Justice release dated July 17, 2025. Medicaid paid $680 in the last 12 observed months.
1	PHYSICIAN HMO INC. Rio Piedras, PR, ranked 460	$0	Adjudicated (pleaded guilty) per a Department of Justice release dated July 17, 2025. No Medicaid payments in the last 12 observed months.
2	YAMIR GARCIA SEGARRA Caguas, PR, ranked 696	$1.9M	Billed more hands-on hours than a day holds in 3 months, peaking at 22.2 hours per day across 3 billing organizations. Medicaid dollars per patient on code 92526 ($630 per patient-month) sit in the top 5% of every provider billing that code.
3	CMS HOME CARE NORTE, LLC Hatillo, PR, ranked 3502	$0	Part of provider network D1-00068, ranked 68 nationally.

All 81 in PR

Recent enforcement in PR

All releases

Department of Justice and HHS-OIG releases for this state, newest first. Each opens in a new tab.

DOJIndictedJun 23, 2026

2026 National Health Care Fraud Takedown

Four defendants were charged in two schemes, one involving the advertising, sale, and distribution of Semaglutide, Mounjaro, steroids, and Tirzepatide that defendants were not authorized to possess and distribute, and the other involving performing dental procedures on patients without a valid dental license and misbranding of devices.

DOJCivil settlementJun 4, 2026

Puerto Rico Pharmacies Agree to Pay $4.6 Million to Federal Authorities in Medicare and Medicaid Fraud Cases

Four pharmacies and their owners agreed to pay $4.6 million to resolve allegations that between January 2021 and January 2024 they billed Medicare and Medicaid for diverted prescriptions sold to patients that had been misrepresented as properly sourced despite unverifiable origins.

DOJPleaded guiltyJul 17, 2025

Physician Assistant who Pretended to be a Licensed Physician Pleads Guilty to Making False Statements to an Agency of the United States

Villalobos-Meléndez, a licensed physician assistant who was never licensed to practice medicine, forged medical license and USMLE documents, worked as a physician in a hospital internship program, and submitted false license information on a CMS-855I form seeking enrollment as a Medicare physician provider with benefits reassigned to Physician HMO.

DOJCivil settlementDec 23, 2024

MMM Holdings, LLC Agrees to Pay 15.2 Million Dollars to Resolve Allegations that it Violated the False Claims Act and Anti-Kickback Statute

MMM Holdings distributed gift cards to administrative assistants of providers to induce the referral, recommendation, or arrangement for enrollment of thousands of Medicare beneficiaries in an MMM Medicare Advantage plan and submitted or caused claims for payment to Medicare.

DOJIndictedSep 25, 2024

27 Individuals Indicted for Buying and Selling Wholesale Quantities of Misbranded and Diverted Prescription Drugs Resold to the Public Through Retail Pharmacies in Puerto Rico

Defendants engaged in unlicensed wholesale distribution of misbranded and diverted prescription drugs sold to pharmacy owners and employees who resold them to customers and billed health care benefit plans as if the drugs were authentic and obtained through licensed distribution channels.

Referral packet

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