Texas doctor & 6 others arrested in $350 million Medicare fraud scheme

WTF Texas Medicare fraud hp 2.29.12

A Texas doctor and six co-conspirators were arrested yesterday in what federal authorities called one of the largest Medicare scams in history.

The Justice Department has indicted Dr. Jacques Roy for allegedly organizing a health care fraud ring that bilked Medicare and Medicaid out of nearly $375 million between 2006 and 2011. 

“This represents the single largest fraud amount orchestrated by one doctor in the history of our Medicare Fraud Strike Force operations,” said Deputy Attorney General James Cole. “We will aggressively investigate and prosecute those who seek to defraud the American people.”

Medicare Part A reimburses healthcare agencies that provides medical services to Medicare beneficiaries who are homebound due to illness or disability. To qualify for Part A reimbursement, the services provided at a patient’s home must be medically necessary and ordered by a doctor.

Prosecutors allege that Roy and his company, Medistat Group Associates, falsely certified more than 11,000 Medicare beneficiaries for home health services that weren’t needed.

“Many of these Medicare beneficiaries had primary care physicians who never certified home healthcare services for them,” according to the federal indictment.

Home healthcare agencies colluding with Roy billed Medicare for medical services or home visits that were not necessary or not performed at all. In exchange for providing the false certifications, Roy received kickbacks from the agencies defrauding Medicare.

Prosecutors estimate that Medistat and 500 affiliated home healthcare agencies billed Medicare for over $350 million and Medicaid for $24 million during a five-year span.

Roy was charged with one count of conspiracy and 10 counts of health care fraud. His office manager, Teri Sivils, was charged with conspiracy for her role in falsifying medical records.

The indictment also charged owners of three health care agencies of conspiring with Roy to commit health care fraud:

  • Charity Eleda, R.N., co-owner of Charry Home Care Services, Inc. in Dallas, Texas. 79% of Charry’s patients were certified by Medistat. The company billed $469,000 to Medicare for those patients. Eleda allegedly recruited Medicare beneficiaries at a Dallas homeless shelter and provided services in her vehicle or a park bench near the shelter. After she was removed from the shelter several times, Eleda would treat the supposedly homebound patients at a nearby church.

If convicted, the conspiracy charge carries a maximum sentence of 10 years in prison and a $250,000 fine. Each health care fraud charge carries a maximum sentence of 5 years in prison and a $250,000 fine. In addition, federal prosecutors are seeking forfeiture of the defendants’ properties and income obtained through fraud.

Since 2009, the Justice Department has recovered more than $10.6 billion in health care fraud cases. Federal prosecutors won 700 convictions against 1,400 defendants in 500 nationwide cases last year.

To learn more about stopping Medicare fraud, please visit StopMedicareFraud.gov. To report Medicare or Medicaid fraud, please call 1-800-447-8477 to reach the Office of the Inspector General at U.S. Health and Human Services.


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