Seven Individuals Arrested for Alleged Participation in $375 Million Health Care Fraud Plot

Last week, the Department of Justice unsealed an investigation into Dr. Jacques Roy, his office manager, and five home health agency owners’ alleged participation in a nearly $375 million healthcare fraud scheme.  All seven were accused of submitting false claims to Medicare and Medicaid for home health services.

Medicare is administered by the US Department of Health and Human Services through the Centers for Medicare & Medicaid services (“CMS”).  Some home healthcare services provided by home healthcare agencies (“HHA”) are covered by Medicare.  Rather than paying the Medicare beneficiaries, payments for these services are made directly to the HHAs or healthcare providers based on claims they submit to the Medicare program.  In this case, CMS contracted a company called Trailblazer Health Enterprises to administer the Medicare home healthcare services and pay the claims submitted by HHA providers.  One of the many documents HHAs need to submit to be reimbursed for their services is a Plan of Care, signed by a physician, which orders the home healthcare and outlines the services the patient would need as a part of their care.  Another requirement is a signed certification statement by a doctor certifying that the patient is confined to his or her house and requires home health services.  Dr. Roy and his cohorts allegedly submitted nearly $375 million in false claims by taking advantage of this process.

Dr. Jacques Roy was licensed in Texas and owned Medistat Group Associates.  Medistat’s primary role was to provide home health certifications and to perform patient home visits.  Roy was accused of certifying and recertifying Plans of Care so that the involved HHAs could bill Medicare for home health services that were either medically unnecessary or were never performed.  Additionally, Roy was accused of performing unnecessary home visits and ordering unnecessary medical services for the Medicare beneficiaries he certified.  According to the indictment, over the course of 5 years, Medistat certified more Medicare beneficiaries for home health services and had more patients than any other medical practice in the United States.  This would have made Medistat the busiest Medicare practice in the country.  Roy’s office manager, Teri Sivils, was the individual at Medistat directly responsible for ensuring that Plans of Care were processed.  She was accused of signing Roy’s name to the Plans of Care and supervising the processing of these plans, permitting the HHAs to bill Medicare for the unnecessary home services.

The HHAs involved in this case are Apple of Your Eye Health Care Services, Inc., owned by Cynthia Stiger and Wilbert James Veasey, Jr.; Ultimate Care Home Health Services, Inc., owned by Cyprian Akamnonu and Patricia Akamnonu, R.N.; and Charry Home Care Services, Inc., owned by Charity Eleda, R.N.  All three are located in Texas and operate around the state.  According to the indictment, 80% of Apple’s patients were certified for home healthcare services by physicians at Medistat.  Additionally, Stiger and Veasey were accused of submitting claims to Medicare for $9,157,646.09 for services for Medicare beneficiaries certified by Medistat.  78% of Ultimate Care’s patients were certified for home healthcare services by Medistat physicians.  Ultimate submitted claims to Medicare for these patients for $43,184,628.32.  79% of Charry Home Care Services’ patients were certified for their home care by Medistat.  Charry submitted claims to Medicare for these patients for $468,858.14.  In order to generate so much activity, the HHAs allegedly offered Medicare beneficiaries cash, free groceries, or food stamps in return for giving their names and Medicare numbers.

Although there should be systems in place to flag such off the charts billing, it took internal information from a whistleblower to finally alert the government to Roy and the HHAs fraudulent activity.  Roy’s business manager, identified only by his initials in the indictment, became aware of the fraud and filed the initial qui tam lawsuit against his employer.  While the Medicare Care Fraud Strike Force has started to develop better methods to detect such rampant abuse of the system, whistleblowers are still the best and most reliable fraud detectors.  If you know about fraud being committed, contact the experienced attorneys of Tycko & Zavareei, LLP today.

To read more about Dr. Roy and this case, check out the following links:

http://www.justice.gov/opa/pr/2012/February/12-crm-260.html

http://www.washingtonpost.com/business/industries/texas-medical-group-owner-among-7-indicted-in-alleged-375-million-health-care-fraud-scheme/2012/02/29/gIQAzfMchR_story.html?tid=pm_business_pop

http://www.nytimes.com/2012/02/29/us/seven-charged-in-texas-medicare-and-medicaid-fraud.html

http://www.npr.org/blogs/health/2012/02/28/147576819/feds-accuse-texas-doctor-in-350-million-medicare-fraud

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