Last year, government investigators found that the federal program for vetting the health of green card applicants included scores of doctors with histories of professional misconduct. Physicians who had been disciplined by state medical boards for abusing patients, and in some cases had faced criminal charges, had the government’s blessing to conduct screenings that can decide the fate of an immigrant’s petition for permanent residency.

The investigators found one doctor who had been convicted of hiring a hitman to kill a disgruntled patient, and in the same sample, found more than a hundred other physicians with serious disciplinary histories. The review concluded that U.S. Citizenship and Immigration Services, the agency that maintains the list of more than 5,000 doctors, inadequately vets the physicians, and that it often fails to follow its own standards. “As a result of these deficiencies, USCIS may be placing foreign nationals at risk of abuse by physicians performing medical examinations,” investigators concluded.

Fifteen months after the audit was released, the list still includes scores of doctors with histories of professional misconduct similar to those flagged in the audit. In the directory of so-called civil surgeons, ProPublica found at least 150 doctors accused of patient abuse and negligence as of early December, and we determined that many of them are still offering the exam.

One is James Richard Luu, of San Jose, California, who allowed his sister, an acupuncturist, to use his prescription pad and to treat patients with hemorrhoids in his office, misdiagnosing them and causing pain. Luu, 53, came to the United States as a refugee from Vietnam, and he and his sister placed ads in Vietnamese-language media to recruit patients from the immigrant population in San Jose. In 2011, Luu was charged with aiding and abetting the unlicensed practice of medicine in relation to his sister. He pleaded guilty, was sentenced to one day in jail and one year of probation. In 2014, the medical board put him on professional probation for three years.

He is currently offering immigration exams, and he said he has had no issues since he was put on probation in 2014. “Everything has been cleared.”

Another doctor who was in the good graces of USCIS for years is Alvaro Genao, of New York City, who forged another physician’s name to prescribe medications, including a potentially addictive sleep aid, to himself and others. After an investigation, the state medical board suspended his license in 2014, for professional misconduct and fraudulent practice. In 2017, the medical board withdrew the suspension, putting him on probation for 10 years.

Genao, 49, was still listed on the USCIS website until last week when he was removed after ProPublica contacted the agency. He did not respond to emails or text messages and hung up when a ProPublica reporter called him.

After the audit last year, USCIS promised to clean up the list and take actions to prevent green card applicants from being exposed to potential harm. But USCIS does not require any consideration of doctors’ disciplinary histories when they apply for the program. The agency requires only that applicants have an active medical license, and almost all of the doctors on the list who have serious records do.

The audit noted that doctors who have had issues with misconduct in the past could still present a risk to patients. “Although some disciplinary conduct may have occurred years ago, the nature of the offense may continue to render these physicians a risk to those applying for immigration benefits,” the report said.

It recommended that USCIS, which is part of the Department of Homeland Security, develop stricter standards, like those used by the Department of Health and Human Services, under which many of the physicians on the agency’s directory could be disqualified. But the agency has already missed several self-imposed deadlines to make fixes. The audit also suggested using the National Practitioner Data Bank, a federal database, to bolster the vetting of doctors.

The doctor who was convicted of hiring the hitman was removed from the USCIS website this summer, along with about two dozen others. But our analysis found that as of early last week, more than a hundred doctors with records of unprofessional and sometimes dangerous behavior are still listed online.

After ProPublica contacted USCIS on Dec. 4 — and before it provided any response to our inquiry — the agency removed 16 more doctors with a history of misconduct from the website. In an email, the USCIS press office said, “Due to a computer glitch, civil surgeon revocations made in the past few weeks were not reflected online. USCIS has corrected the issue.” But many of the doctors who were removed last week, including Genao, were disciplined several years ago.

One of the doctors with the USCIS stamp of approval admitted to a state medical board that in the early 1990s he had “sexual relations” with at least 16 of his patients. He is still listed online. Another doctor, who investigators found provided substandard care to green card seekers in a makeshift office without an exam table, was specifically barred from doing work related to USCIS. He was removed from the directory last week after ProPublica’s inquiry.

To assess the state of the USCIS list, ProPublica analyzed the disciplinary records of doctors in the top five states for green card applications. In 2017, 57% of green card applications filed within the U.S. were sent from California, Florida, Texas, New York and New Jersey. We entered every ZIP code from those five states into the USCIS Find a Doctor website, and we looked up the medical board disciplinary record of each doctor who appeared in the search results.

We considered doctors to have a history of unprofessional or dangerous behavior if they had been disciplined for sexual misconduct, drug abuse, negligent patient care, inappropriate prescribing of controlled substances or deceptive practices. We did not include doctors who were disciplined for administrative errors like failing to submit a death certificate or not updating a practice’s address with the medical board.

We found dozens of doctors who improperly prescribed controlled substances to themselves, friends or family members; some who violated patient privacy by revealing medical records to unauthorized people; some who failed to supervise assistants and technicians; and others who improperly diagnosed and documented medical conditions.

“It is horrible to know that there are doctors out there that have been disciplined for this type of action, and that they’re responsible as gatekeepers to these immigrants,” said Mario Urizar, an immigration lawyer in Miami whose firm handles more than 100 cases of green card applications annually.

The audit, issued in September 2018, was conducted by the inspector general for the Department of Homeland Security. It listed eight recommendations, including stricter requirements for doctors and improved training for the USCIS staff reviewing doctors’ applications. USCIS agreed and set projected completion dates. Two of those dates have passed and two more are at the end of this year.

In an email, USCIS’s press office wrote that the agency has “begun implementing the recommendations.”

“USCIS concurred with last year’s Inspector General report and continues toward implementation of recommendations, including drafting updated policy to develop stricter eligibility requirements for civil surgeons and strengthening the health-related inadmissibility training program,” a spokeswoman, Marilu Cabrera, said in a statement.

While the Trump administration’s focus on illegal immigration has captured the nation’s attention, the federal government has also made the pathways to legal immigration more challenging. Immigration lawyers told ProPublica that recent changes in USCIS policies have made it difficult to correct mistakes in green card applications, raising the stakes for the immigrants, doctors and attorneys who fill out the forms.

The case of Fernando Romero illustrates how a single mistake by a USCIS-designated doctor — even one without a disciplinary record — can upend a petition for permanent residency. Romero, 41, traveled to Miami from Argentina almost two decades ago, when Argentine tourists could enter the U.S. with a visa waiver. He overstayed his visa waiver and was undocumented for several years. In 2016, he applied for a green card through his wife, also an Argentine immigrant, who had become a U.S. citizen years earlier. Last July, the petition was denied. In a letter, USCIS said it had turned down Romero’s application because the doctor who examined him didn’t include her contact information in the medical form. (The doctor who examined Romero is not on ProPublica’s list of doctors with serious disciplinary records and declined to comment for this story.)

The letter from USCIS instructed Romero to make arrangements to leave the United States “as soon as possible.” If he didn’t, he could be barred from entering the country or receiving any immigration benefits, the letter said.

“When we got the letter, we panicked. My wife and I started wondering, what are we going to do? Are we going to have to return to Argentina?” said Romero, who installs wood flooring for a living. “I feared that the feds were going to knock on my door any day.”

Under a past policy, implemented during the Obama administration, the USCIS officer working on Romero’s case would have been likely to notify Romero about the missing contact information. But last September, the agency changed its policy. Now, officers aren’t required to send a notification, although they can. The agency has said that it made the change to cut down on “frivolous” green card applications, and that it was not intended to penalize applicants for “innocent mistakes” or misunderstandings.

In October 2018, USCIS also changed the appointment system for many of its field offices, limiting in-person meetings between applicants or their attorneys and the agency’s officers. In a press release, USCIS said the change was part of an effort to move more services online and reduce case processing times.

But attorneys say that these changes leave immigrants like Romero with few options to address issues with their applications.

Read USCIS’s Letter to Fernando Romero

In its letter denying Romero’s green card petition, USCIS advised him that his only other option was to file a “motion to reopen or a motion to reconsider” his case, which carries a $675 filing fee. Even if that succeeded, it would have likely meant starting the costly and lengthy green card process all over again. In the meantime, neither his driver’s license nor his work permit would be valid.

“The whole time while they do that, I essentially would have gone back to zero… as if I was here illegally again,” said Romero, who had already spent more than $4,000 on the application and legal fees.

Romero said he called the agency dozens of times, hoping to correct the doctor’s mistake by submitting a new medical form, instead of restarting the application process. But he said everyone he reached at USCIS referred him to the letter. He said that he and his wife talked to nearly 20 attorneys, but all of them offered only to file the motion. Eventually he reached Urizar, the lawyer in Miami, who suggested Romero sue USCIS. The lawsuit, filed in August, claimed that the USCIS was arbitrarily punishing Romero for a mistake by a doctor who was working on behalf of the agency. Two weeks later, the USCIS agreed to allow Romero to submit the corrected form and approved his green card.

The immigration medical forms are only valid for two years. If the process takes longer, an applicant would have to see a USCIS-designated doctor again and pay another exam charge. The medical exam, which is not covered by insurance, has no fixed price. In phone calls to doctors’ offices, ProPublica was given prices ranging from $100 to $1,000.

Immigrants “are completely vulnerable because the doctor gives them the report in a sealed envelope to provide immigration with,” Urizar said. “So not only are they not privy to their documents unless they ask for a copy, they have no say as to what immigration will decide on it.”

According to USCIS, the purpose of the immigration medical exam is to protect public health. A green card applicant may be deemed inadmissible on medical grounds, a power established in the Immigration Act of 1891, which stated that entry could be denied to all “idiots, insane persons, paupers or persons likely to become a public charge,” as well as “persons afflicted with tuberculosis or with a loathsome or dangerous contagious disease.”

Although the conditions that could render a person inadmissible today are no longer described as loathsome, the same principles apply to current immigration exams. Tuberculosis remains a part of the screening, along with communicable diseases such as syphilis, gonorrhea and leprosy. Drug addiction, considered a disorder “associated with harmful behavior,” is also listed as grounds for denying an immigrant entry.

Last year, just over 2,700 immigrant visa applications were rejected for medical reasons, according to data from the State Department. Nearly 1,000 of these applications cited communicable disease as the cause for ineligibility. The data does not show how many of these immigrant visas are connected to green card applications.

The list of conditions that could make an immigrant inadmissible has been the subject of controversy. The Centers for Disease Control and Prevention removed HIV from the list in 2010, stating that including HIV was “at odds with human rights considerations,” after Congress repealed a travel ban on tourists and immigrants who were HIV-positive. Until 1973, when homosexuality was removed from the official list of mental illnesses in the U.S., the medical exam could be used to bar LGBTQ applicants.

The term civil surgeon is a holdover from the days of Ellis Island. The original screeners were officers of the U.S. Public Health Service, led by the surgeon general. Civil surgeons today do not have to be civil servants or surgeons. Most are private doctors, and the process to become certified is simple: Any physician who is authorized to work in the United States, has four years of professional experience and is licensed without restriction in the state where they work can apply by filling out a form and paying a $785 filing fee. State and local health department physicians and military physicians are automatically eligible.

Francisco Velazquez, an internist in the Houston area, said he became a USCIS-designated doctor to serve the immigrant community. Velazquez said he was motivated to join the program after hearing about clinics that were charging a lot and prescribing unnecessary vaccines.

“It’s just a numbers game,” Velazquez said. “It adds up, and if you’re very greedy and you charge a little bit more here and there, the demand is there.”

Velazquez, who became a civil surgeon last October, sees 30 to 40 patients a month for the immigration exam. He said that most of the immigrants who come to his office are working-class people who are referred by immigration attorneys. Others have found his office while calling different doctors looking for a price they can afford. He charges $265 per exam, plus the cost of any vaccinations the applicants need. To avoid mistakes, he says he types the information in the form, instead of writing by hand, and gives a copy to the patient to review.

Physicians in the program are required to follow the CDC’s instructions for administering and evaluating the exams. The CDC also runs conferences and workshops for the doctors on how to administer the exams properly, but attendance is voluntary.

USCIS has a history of significant lags in updating and maintaining its list of approved doctors. In May 2017, the inspector general sent a list of 48 doctors to USCIS whose licenses were restricted or expired. It took several months for the agency to act, and in the end 11 of them were never removed.

Physicians are required to notify USCIS within 15 days if they stop practicing or stop administering immigration exams. The agency’s press office said that when USCIS revokes a civil surgeon’s designation, it removes that doctor from the directory. But ProPublica found at least a dozen physicians whose offices said they were no longer giving green card exams in mid November, even though they were still listed as doing so online.

According to the inspector general’s report, USCIS relies on a contractor specializing in health care compliance to review the list of doctors twice a year and identify those with inactive or restricted licenses. Then, a USCIS employee manually reviews the results.

Last year, the inspector general’s audit recommended that USCIS stop using the contractor, Evercheck. The audit called the agency’s process inefficient and suggested that USCIS use the National Practitioner Data Bank, which is run by Health and Human Services.

USCIS’s press office said in an email that the agency is still using Evercheck to confirm that physicians are licensed and to identify any restrictions on the licenses. The agency said it has increased license reviews to four times a year. The office also wrote that the agency is still “determining how best to utilize the National Practitioners Data Bank (NPDB) in a manner that is feasible, cost effective, and appropriate for the agency’s needs.”

In an email, Brian Solano, the CEO of Evercheck, said that the company has had the same contract with USCIS for several years, and that the terms have not changed. He said that he was not aware of the audit.

Solano wrote that Evercheck provides monthly reports of doctors’ license statuses, including disciplinary actions taken against them. But it’s up to USCIS to decide what to do with those reports.

“We’re just alerting them of any changes on the license,” Solano said. “And then they can make the business decision of what to do about it.”

Of the audit’s eight recommendations, all but one — creating a training program and quality control for the designation of physicians — remain open, according to Tanya Alridge, a spokeswoman for the inspector general. The inspector general’s office said that agency liaisons check in on the status of open recommendations every 90 days, and that progress is reported to Congress twice a year.

How We Reported This Story

To assess the doctors authorized to perform immigration exams, ProPublica analyzed the disciplinary records of more than 4,000 doctors who are designated as civil surgeons. We scraped USCIS’ Find a Doctor website, which is the public list of civil surgeons, according to USCIS’s policy manual. We entered every ZIP code from the top five states for green card applications (California, Florida, Texas, New York and New Jersey) and scraped and saved those search results. For each doctor that showed up in the search results, we looked up their disciplinary record from the state medical board website, which is public information. We matched the doctors on their first and last name (and middle name, if one was listed), and the state in which they were listed as practicing on USCIS’ website. If multiple doctors had the same name in the same state, we cross-checked the name of their practice and ZIP code.

We read through the medical board findings on each doctor’s misconduct. We considered doctors to have a record of unprofessional behavior if they had been disciplined for sexual misconduct, drug abuse, negligent patient care, inappropriate prescribing of controlled substances or deceptive practices. For example, we included doctors that prescribed controlled substances to their friends and family members, posted false advertisements about their treatments, administered watered down or expired vaccines and medications, sexually assaulted and harassed patients, and allowed staff members who were not medically trained to treat patients. We did not include doctors that were disciplined for administrative errors, such as failing to submit a death certificate or neglecting to update information such as their address or phone number with the medical board.