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.
More than 75 of the agencies that used Roy's signature to certify claims also have had their Medicare payments suspended.
Some of those indicted alongside Roy are accused of fraudulently signing up patients or offering them cash, free groceries or food stamps to give their names and a number used to bill Medicare. Medicare patients qualify for home health care if they are confined to their homes and need care there, according to the indictment. U.S. Attorney Sarah Saldana said some people supposedly eligible for home care were found working on their cars outside.
Roy is accused of signing off on paperwork for home health care services.
Health and Human Services Inspector General Daniel Levinson described Roy's billing on Tuesday as "off the charts." But it apparently was missed for years by claim reviewers.
Carmen Irwin, a CMS health insurance specialist, said a claim reviewer may have difficulty immediately noticing how often a single doctor's signature is being used.
"We're paying a home health agency," Irwin said. "We're not necessarily looking at how many claims are for one physician because we're not necessarily paying a physician on a home health claim."
Patrick Burns, spokesman for the advocacy group Taxpayers Against Fraud, praised HHS for hiring Peter Budetti, CMS' deputy administrator for program integrity, to upgrade its systems. But Burns said the department had no excuse for missing obvious problems.
"You can't have 11,000 bills from a single doctor if you're the number one home health provider in the nation," Burns said. "You can't see that many patients. It's not physically possible."