A 60-year-old physician from Texas was sentenced today to 35 years in federal prison for his role in a massive health care fraud scheme worth an estimated $374 million.
Jacques Roy, who was convicted last year in one of the largest home health care fraud cases in history, was sentenced by U.S. District Judge Sam A. Lindsay and ordered to pay over $268 million in restitution, joint and several with all co-defendants to government health care agencies.
Roy was convicted of eight counts of health care fraud, two counts of making a false statement relating to health care matters, one count of conspiracy to commit health care fraud and one count of obstruction of justice. He has remained in custody since his arrest in Feb. 2012.
Other defendants previously sentenced for their roles in the Dallas health care fraud scheme include:
- Wilbert James Vesey, Jr. – 10 years in federal prison and $23 million in restitution
- Cyprian Akamnonu – 10 years in federal prison and $25 million in restitution
- Patricia Akamnonu – 10 years in federal prison and $25 million in restitution
- Charity Eleda – 4 years in federal prison and $397,294.51 in restitution
- Teri Sivils – 3 years of probation and $885,714.05 in restitution
Another defendant, Cynthia Stiger is scheduled to be sentenced for her role in the fraud scheme on Oct. 26, 2017.
Medistat Fraud Conspirators Paid Kickbacks for Patient Referrals and Falsified Medical Records
During Dr. Roy’s trial last year, the government presented evidence that he, Stiger, Veasey, and Eleda were active participants in a massive fraud scheme in which they conspired together and with others to defraud government health care agencies using companies they either owned or controlled.
These companies included:
- Medistat Group Associates, P.A.
- Ultimate Care Home Health Services
- Apple of Your Eye Health Care Services, Inc.
- Charry Home Care Services.
According to the Justice Department, Stiger, Eleda, and Veasey along with others, improperly recruited Medicare beneficiaries to sign up for home health care services. Eleda recruited patients from The Bridge homeless shelter in Dallas, sometimes paying recruiters $50 for each beneficiary they found and sent to her.
Eleda and other nurses were also accused of falsifying records to make it appear that Medicare beneficiaries qualified for home health care services when such services were not considered medically necessary. Eleda and the nurses prepared medically unnecessary Plans of Care (POC), also referred to as 485s, which were delivered to Dr. Roy’s office and were not properly reviewed by a doctor.
According to the allegations, Dr. Roy instructed staff to falsely certify these POCs, which indicated to Medicare and Medicaid that a doctor had reviewed the plans and deemed them medically necessary. The doctor who signed off on the plans, most commonly Dr. Roy, certified that patients required home health services, which were only permitted to be provided to individuals who were homebound and required, among other things, skilled nursing.
This process of falsely certifying beneficiaries for home care was repeated thousands of times, according to DOJ. In fact, Medistat’s office included a “485 Department,” which was essentially a “boiler room” to fraudulently certify POCs requiring home health services for beneficiaries.
After certifying beneficiaries for home health care services, Eleda, nurses who worked for Stiger and Veasey, and others involved in the fraud scheme falsified medical records to make it appear as though skilled nursing services were being provided to patients and continued to be necessary. Dr. Roy would also perform unnecessary home visits and order unnecessary medical services for the recruited beneficiaries. At Dr. Roy’s instruction, Medistat staff submitted fraudulent claims to Medicare for the certification and recertification of unnecessary home health care services and other unnecessary medical services.
With regard to Dr. Roy’s conviction for obstruction of justice, the government found that when the Centers for Medicare and Medicaid Services (CMS) suspended Dr. Roy and Medistat from receiving Medicare payments in 2011 due to suspected fraud, Dr. Roy sought an “end-run” around the suspension through the use of another company, Medicare House Calls. Dr. Roy directed the medical providers he employed to be re-credentialed and to bill Medicare under Medcare House Calls, despite the fact that the money eventually made its way to Medistat and Dr. Roy.
“The only thing more stunning than Jacques Roy and his co-conspirators’ shameless methods is the staggering dollar amounts involved in this fraud scheme. This takes brazen to a whole new level.” – U.S. Attorney John Parker of the Northern District of Texas
The government’s investigation showed how massive the home health care fraud scheme was: Medistat processed and approved POCs for roughly 11,000 unique Medicare beneficiaries from more than 500 different home health agencies.
Massive Health Care Fraud Case in Texas Underscores Need for Whistleblowers
The fraud charges against Jacques Roy and his co-conspirators demonstrate how far some are willing to go to line their own pockets at the expense of government health care agencies. Health care fraud on any scale not only threatens to disturb the integrity of our health care system, but it also compromises patient care.
This is why whistleblowers are a necessary weapon to combat health care fraud and abuse. If someone would have tipped the government off about the fraud and wrongdoing outlined in this case, it could have prevented more taxpayer dollars from being wasted, and the whistleblower who brought the allegations to the government’s attention likely would have received a sizable reward, potentially worth tens of millions.
“Especially when physicians cheat the government, we all pay the price. The skyrocketing cost of health insurance and threats to decrease Medicaid and Medicare coverage can best be prevented by reporting fraud and becoming a whistleblower. The criminals get caught and we all benefit.” – Diane Marger Moore, a whistleblower attorney
If you have knowledge of health care fraud and abuse being committed in your place of work, it is in your best interest to speak with an experienced whistleblower attorney about your case. Your willingness to come forward and preserve the integrity of our health care system could help put an end to fraud and earn you a sizable whistleblower reward.