Updated on: June 22, 2012

Doctor Nabbed in Almost $375 Million Fraud Scheme

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Original story posted on: March 5, 2012

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A Dallas-area doctor, practice manager and five home health agency owners have been charged with participating in an almost $375 million scheme - the largest amount in the history of the Medicare fraud strike forces.

 

And it might not stop there. CMS suspended payments to 78 more home health agencies associated with the doctor.

 

Dr. Jacques Roy certified or directed staff to certify home health services for 11,000 patients at 500 agencies from January 2006 to November 2011, according to a CMS press release.

 

In 2010 alone, he certified more than 5,000 patients, compared with the 99 percent of physicians certifying home health patients who "signed off on 104 or fewer people," HHS Inspector General Daniel Levinson said. Those numbers were discovered by HHS' data analysis.

 

The indictment alleges that Roy's practice, Medistat Group Associates P.A., had a department of employees who were directed to sign his name or use his electronic signature to certify the patients for home health, the CMS press release stated.

 

Three home health agencies - Apple of Your Eye Healthcare Services, Ultimate Care Home Health Services and Charry Home Care Services - recruited beneficiaries to become home health patients so the agencies could bill for services that were unnecessary or not provided, the press release stated.. One agency owner recruited so-called patients from a Dallas homeless shelter.

 

CMS had suspended Roy's provider number in June 2011, based on "credible allegations of fraud," a term defined in a Medicare screening rule that went into effect last year, the press release stated.

 

RACs Post DME, Inpatient Hospital Issues

 

HealthDataInsights, the Region D RAC, posted six inpatient hospital issues while Connolly, the Region C RAC, posted one durable medical equipment issue. See below for more details.

 

Inpatient hospitals

 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Acute inpatient hospitalization - craniotomy and endovascular intracranial procedures with CC (DRG 026)

2/27/12

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

Acute inpatient hospitalization - cardiac inplant, valve and bypass procedures (DRGs 215, 218, 219, 220, 221, 231, 232, 233, 234, 235)

2/27/12

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

Acute inpatient hospitalization - ortho procedures except major joint (DRGs 255, 474, 480, 481, 482, 492, 616, 617, 618)

2/27/12

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

Acute inpatient hospitalization - female reproductive system OR (DRGs 734, 735, 736, 737, 738, 739, 740, 744, 749, 750)

2/11/12

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

 



 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Acute inpatient hospitalization - intra- and extracranial procedures (DRGs 020, 021, 022, 037, 038, 039, 040)

2/11/12

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

Acute inpatient hospitalization - head and neck procedures (DRGs 035, 036, 129)

2/11/12

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

 

 

Durable medical equipment

 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Incorrect billing of group III pressure-reducing support surface

2/22/12

RAC Region C

Group III pressure-reducing support surface HCPCS code(s) were not billed with the required ICD-9 diagnosis code(s) or billed in conjunction with a noncovered diagnosis code.

CGS Administrators LCD L11565; National coverage determination for air-fluidized bed (280.8)

 

About the Author

 

Karen Long is the compliance product manager for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation's leading independent authority on home healthcare business, regulation and reimbursement.

 

Contact the Author

 

KLong@decisionhealth.com

 

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