On Tuesday, the Obama administration announced that a Texas physician and the owners of five home health agencies were arrested for allegedly defrauding Medicare and Medicaid of nearly $375 million, the Washington Post reports.
According to administration officials, it is the largest case of home health care fraud ever committed and the biggest case to be brought against a single physician.
About the Scheme
Jacques Roy, the physician and owner of Medistat Group Associates, allegedly organized the scheme over the past six years (Horowitz, Washington Post, 2/28). "Between January 2006 and November 2011, Medistat certified more Medicare beneficiaries for home health services and had more purported patients than any other medical practice" in the U.S., the Department of Justice and HHS said in a joint statement (Fox, National Journal, 2/28).
According to investigators, Roy or others certified 11,000 beneficiaries who were recruited by a network of more than 500 home health service agencies, and then billed Medicare for services and home visits that were unnecessary or not provided (Washington Post, 2/28).
Some of the owners are accused of luring beneficiaries into the scheme by offering no-cost health care and other incentives, such as food stamps, in exchange for Medicare identification numbers, the AP/New York Times reports.
CMS also suspended another 78 home health agencies linked to Roy. The agencies have been collecting about $2.3 million monthly, according to Peter Budetti, CMS' deputy administrator for program integrity.
HHS Previously Unable To Track Large-Scale Fraud
According to the AP/Times, HHS until recently was unable to effectively track data associated with large-scale fraud.
HHS Inspector General Dan Levinson said that the department's technology "has not come online as quickly as we'd like to see."
As a result, the alleged fraud linked to Roy continued for several years. Even when CMS suspended Medicare provider accounts for Roy and Medistat in 2011, company employees began billing Medicare under a different provider number.
Levinson said that HHS is strengthening its data analysis (AP/New York Times, 2/28). HHS officials added that the federal health reform law granted the department new detection tools that helped them with the case (Pecquet, "Healthwatch," The Hill, 2/28)
Levinson 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" (AP/New York Times, 2/28).