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Medicare Compliance & Reimbursement

Fraud & Abuse:

78 HHAs Put On Suspension At Once As Part Of Fraud Bust

Published on Tue Apr 17, 2012

Be careful about which docs certify your patients for home care.

It's not just home care providers getting collared in massive home care fraud schemes. The feds have charged a physician and his office manager in a $375 million fraud ring in the Dallas area.

The charges: Physician Jacques Roy owned and operated Medistat Group Associates. Medistat was an association of health care providers that primarily provided home health certifications and performed patient home visits, the Department of Justice says in a release. Dr. Roy allegedly certified or directed the certification of more than 11,000 individual patients from more than 500 HHAs for home health services during the past five years, the DOJ says. Many of those were for medically unnecessary services and services never provided.

Medistat allegedly maintained a "485 Department," the DOJ says. Dr. Roy instructed Medistat employees to complete the 485s by either signing his name by hand or by using his electronic signature on the document, prosecutors charge. Medistat and the charged HHAs -- Apple of Your Eye Healthcare Services Inc., Ultimate Care Home Health Services Inc.; and Charry Home Care Services Inc. -- used patient recruiters for the scheme. Recruiters would go to homeless shelters, for example, to find beneficiaries.

Five individuals from the agencies have also been charged: Cynthia Stiger, Wilbert James Veasey Jr., Cyprian Akamnonu, and nurses Patricia Akamnonu, and Charity Eleda.

The named agencies had 79 to 80 percent of their patients certified by Roy, notes the indictment unsealed Feb. 28. Various payments went back and forth between Roy and the agencies, it adds.

Whoa: In addition to the criminal charges, CMS has suspended a whopping 78 additional home health agencies associated with Roy based on "credible allegations of fraud against them," the DOJ says. In all, Roy certified patients for more than 500 HHAs, according to the indictment.

In other cases consultant Julianne Haydel has worked on, CMS will not restore payments until the investigation is complete. "That means that there are effectively 78 fewer agencies in Dallas this week," says Haydel, with Haydel Consulting Services in Baton Rouge, La.

This case shows why it's so important to vet the physicians who are signing your patients' certifications and plans of care, Haydel says. "Check your docs, folks," Haydel urges HHAs. "The state board of medicine doesn't actually report on issues while they are still under investigation."

Remember: "If a physician has a restricted license, be sure that you are fully aware of the restrictions," Haydel adds. For example, some physicians in recovery are not allowed to prescribe scheduled meds.

Feds Comb Through Billing Stats

The bust came as a result of data mining. "Our analysts discovered that in 2010, while 99 percent of physicians who certified patients for home health signed off on 104 or fewer people -- Dr. Roy certified more than 5,000," HHS Inspector General Daniel Levinson says in the release.

"Dr. Roy and his co-conspirators, for years, ran a well-oiled fraudulent enterprise in the Dallas area, making millions by recruiting thousands of patients for unnecessary services, and billing Medicare for those services," Assistant Attorney General Lanny Breuer adds.

"The conduct charged in this indictment represents the single largest fraud amount orchestrated by one doctor in the history of HEAT and our Medicare Fraud Strike Force operations," Deputy Attorney General James Cole says.

"Our aggressive Medicare Fraud Strike Force operations have enabled us to break up a significant alleged fraud operation and the fraud-fighting authorities in the Affordable Care Act have allowed us to stop further payments to providers connected to this scheme," says HHS Deputy Secretary Bill Corr. "This case and our new detection tools are examples of our growing ability to stop Medicare fraud."

More Investigations On The Horizon

"Enough is enough," says lobbying group the Partnership for Quality Home Healthcare in a release. The "indictment in Texas is proof that action is needed now to stop criminals from victimizing the Medicare and Medicaid programs and the vulnerable patient populations they serve." Congress should turn to fraud prevention, rather than HHA pay cuts, to effect Medicare savings, the group implies.

What's next: Expect to see more investigations and mass suspensions ahead, says financial consultant Tom Boyd with Boyd & Nicholas in Rohnert Park, Calif. "This is not the last of it," Boyd predicts. "HEAT and ZPIC will have more coming soon."

With such enforcement actions will come closures for legitimate agencies, Boyd fears. "The sad fact is even those that are not guilty will be shut down," Boyd tells Eli. "The appeal process takes a long time, and meanwhile no Medicare funds."

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