Seven Accused of Bilking $375M from Medicare, Medicaid

By Juan A Lozano and Nomaan Merchant

Dallas - A Texas doctor has been charged with running a massive health fraud care scheme with thousands of fraudulent patients and intermediaries allegedly offering cash, food stamps or free groceries, to bilk Medicare and Medicaid of nearly $375 million.

A federal indictment unsealed Tuesday charges Jacques Roy, a doctor who owned Medistat Group Associates in DeSoto, Texas, and six others in an alleged scheme to bill Medicare for home health services that were not properly billed, not medically necessary or not done.

The scheme was the largest dollar amount by a single doctor uncovered by a task force on Medicare fraud, authorities said.

U.S. Attorney Sarah Saldana accused Roy of "selling his signature" to home health agencies that rounded up thousands of patients' names and billed Medicare and Medicaid for five years.

The indictment alleged that from January 2006 through November 2011, Roy or others certified 11,000 Medicare beneficiaries for more than 500 home health service agencies — more patients than any other medical practice in the U.S. More than 75 of those agencies have had their Medicare payments suspended.

Roy, 54, is charged with several counts of health care fraud and conspiracy to commit health care fraud. He faces up to 100 years in prison if convicted on all counts. He appeared briefly in court Tuesday and is scheduled to have a detention hearing Wednesday. Authorities also moved to seize cash in Roy's bank accounts, cars and two sailboats.

His attorney, Patrick McLain, said authorities had contacted Roy months ago. McLain said it was too soon to comment on the case because prosecutors hadn't provided him with most of the evidence yet. Phone messages and emails left with Medistat, located just south of Dallas, were not immediately returned Tuesday.

The attorney for one of the home health agency owners, Cynthia Stiger, alleged to be part of the scheme called the charges and the dollar amounts listed overblown. Stiger pleaded not guilty Tuesday.

"They're not anywhere close to accurate," said Jeffrey Grass, Stiger's attorney.

Investigators for the U.S. Health and Human Services department noticed irregularities with Roy's practice about one year ago, officials said.

Roy had "recruiters" finding people to bill for home health services, said Saldana, the top federal prosecutor in Dallas. Some of those alleged patients, when approached by investigators, were found working on their cars and clearly not in need of home healthcare, she said.

Medicare patients qualify for home health care if they are confined to their homes and need care there, according to the indictment.

Saldana said Roy used the home health agencies as "his soldiers on the ground to go door to door to recruit Medicare beneficiaries."

"He was selling his signature," she said.

For example, authorities allege Charity Eleda, one of the home health agency owners charged in the scheme, visited a Dallas homeless shelter to recruit homeless beneficiaries staying at the facility, paying recruiters $50 for each person they found. A message was left Tuesday at Eleda's Dallas-based company, Charry Home Care Services, Inc.

Others indicted are accused of offering free health care and services such as food stamps to anyone who signed up and offered their Medicare number.

Roy would "make home visits to that beneficiary, provide unnecessary medical services and order unnecessary durable medical equipment for that beneficiary," the indictment alleged. "Medistat would then bill Medicare for those visits and services."

The indictment says Roy's business manager — identified only by his initials — recorded conversations between the two in January 2006. The business manager heard Roy describe his alleged scheme and refuse to market for patients in a legitimate way, the indictment said.

The Centers for Medicare and Medicaid Services also announced the suspension of an additional 78 home health agencies associated with Roy. The agencies were collecting about $2.3 million a month, said Peter Budetti, CMS' deputy administrator for program integrity.

The alleged fraud went unnoticed for several years. After CMS suspended Medicare provider accounts belonging to Roy and Medistat last July, Medistat's employees allegedly started billing Medicare under a different provider number under Roy's supervision, authorities said.

Until recently, HHS could not effectively track data to identify the kind of fraud now linked to Roy, who was billing beneficiaries "off the charts" for more than five years, officials said. The department's inspector general, Dan Levinson, told reporters the department's technology "has not come online as quickly as we'd like to see."

The department is now beefing up its data analysis and tracking other cases, Levinson said. It has also established task forces in several U.S. cities to track Medicare fraud, officials said.

"We're now able to use those data analytic tools in ways — in 2012 and 2011 — that no, we really could not have done in years past," Levinson said.

A spokesman for Trailblazer Health Enterprises, which paid home health claims through a contract with federal authorities, did not return a phone message Tuesday.

Health care fraud is estimated to cost the government at least $60 billion a year, mainly in losses to Medicare and Medicaid. Officials say the fraud involves everything from sophisticated marketing schemes by major pharmaceuticals encouraging doctors to prescribe drugs for unauthorized uses to selling motorized wheelchairs to people who don't need them.

"These are public programs, and we must protect them for future generations," Saldana said.