Feds: Detecting Possible Home Health Care Fraud Took 5 Years

DALLAS (AP) — The Medicare fraud detection system took years to indicate that a Texas doctor might be certifying thousands of questionable Medicare home health care claims, officials say.

Authorities have indicted the doctor, Jacques Roy, and 6 others in connection with charges of health care fraud.

Roy and the others certified 11,000 Medicare beneficiaries through about 500 home health providers over 5 years, and those certifications led to the processing of about $375 million in false Medicare and Medicaid claims, officials say.

Medicare uses one set of contractors to pay claims and another to evaluate claims for signs of potential fraud.

The investigation that led to the current wave of indictments did not begin until about a year ago, federal officials acknowledge.

But the officials say the Centers for Medicare & Medicaid Services (CMS) has improved its approach to data analysis and is 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, an attorney at the law firm Arnold & Porter, Washington, and a former health care prosecutor at the U.S. Department of Justice.

Roy, 41, a doctor who owned Medistat Group Associates, DeSoto, Texas, has been charged with 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 that he had yet to review much of the evidence and that Roy maintained his innocence. A detention hearing for Roy in federal court was delayed until Monday.