$375M health care scheme went unnoticed for years

February 29, 2012 - 7:35 PM
Healthcare Fraud Scheme

An advertising sign stands outside the offices of Medistat Group Associates in DeSoto, Texas, on Tuesday, Feb. 28, 2012. Dr. Jacques Roy, who ran the business, and six other associates were arrested and charged with recruiting homeless people, among others, as part of a $375 million home health care fraud scheme, authorities announced Tuesday. The federal indictment accused Jacques Roy of leading a scheme that billed Medicare for home health services that were not medically necessary or were not done. Also indicted were Roy's office manager as well as five owners of home health agencies. (AP Photo/The Dallas Morning News, Michael Ainsworth)

DALLAS (AP) — The Texas doctor accused of "selling his signature" to process almost $375 million in false Medicare and Medicaid claims went unnoticed for half a decade by a fraud detection system that some critics say is broken.

Authorities say Jacques Roy and six others indicted for health care fraud certified 11,000 Medicare beneficiaries through more than 500 home health providers over five years. Those numbers would have made Roy's Medicare practice the busiest in the country. But an investigation into Roy and his business practices didn't begin until about a year ago, officials said.

The federal agency that administers Medicare has two sets of contractors: one to pay claims and another evaluating those claims for fraud. U.S. Health and Human Services investigators have found that health officials often have a hard time tracking the work of contractors that are supposed to detect Medicare fraud — estimated by some to reach $60 billion annually.

Federal officials who announced the indictment against Roy and six others in Dallas acknowledged the problems with the system. They contend they have improved data analysis and are working to move away from having to "pay and chase" offenders.

Others say Medicare is still very vulnerable to fraud.

"It's a trust-based system that is ripe for the picking by criminals," said Kirk Ogrosky, a Washington, D.C., attorney at the law firm Arnold & Porter and a former top health care prosecutor at the U.S. Department of Justice.

Roy, 41, a doctor who owned Medistat Group Associates in DeSoto, Texas, faces up to 100 years in prison if he's convicted of several counts of health care fraud and conspiracy to commit health care fraud. Six others, including the owners of three home health service agencies, are also charged.

Roy's attorney, Patrick McLain, said he had yet to review much of the evidence but Roy maintained his innocence. A detention hearing for Roy in federal court was delayed until Monday.

More than 75 of the agencies that used Roy's signature to certify claims also have had their Medicare payments suspended.

Some of those indicted alongside Roy are accused of fraudulently signing up patients or offering them cash, free groceries or food stamps to give their names and a number used to bill Medicare. Medicare patients qualify for home health care if they are confined to their homes and need care there, according to the indictment. U.S. Attorney Sarah Saldana said some people supposedly eligible for home care were found working on their cars outside.

Roy is accused of signing off on paperwork for home health services and pocketing much of the fraudulent billings.

Health and Human Services Inspector General Daniel Levinson described Roy's billing on Tuesday as "off the charts." But it was missed for years by Palmetto GBA, the contractor that paid the home health agencies using Roy's signature, and Health Integrity LLC, the agency tasked with catching any irregularities.

A spokesman for BlueCross BlueShield of South Carolina, which owns Palmetto, referred questions about its fraud procedures to the federal Centers for Medicare & Medicaid Services. Officials at Health Integrity did not return a phone message.

CMS health insurance specialist Carmen Irwin said a screening process is intended to investigate complaints, but it can be difficult to immediately pinpoint a single doctor's signature being used so often.

"We're paying a home health agency," Irwin said. "We're not necessarily looking at how many claims are for one physician because we're not necessarily paying a physician on a home health claim."

A report by the HHS inspector general's office issued in November highlights problems with the contractors charged with weeding out fraud. The contractors reported their findings in different ways and sometimes provided incomplete data, the report found. Some of the information turned out to be inaccurate. Inspectors said "the inconsistencies and lack of uniformity we identified" could prevent effective oversight.

Patrick Burns, spokesman for the advocacy group Taxpayers Against Fraud, credited HHS for hiring Peter Budetti, CMS' deputy administrator for program integrity, to upgrade its systems. But Burns said the department still had no excuse for missing obvious problems.

"You can't have 11,000 bills from a single doctor if you're the number one home health provider in the nation," Burns said. "You can't see that many patients. It's not physically possible."