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Roy Indictment

Roy Indictment

Ratings: (0)|Views: 23,993 |Likes:
Published by Jeff Bair
A Dallas-area doctor has been charged with a $350 million Medicare scheme involving 11,000 home health care patients, the largest home health care practice in the United States, according to an indictment unsealed Tuesday.
A Dallas-area doctor has been charged with a $350 million Medicare scheme involving 11,000 home health care patients, the largest home health care practice in the United States, according to an indictment unsealed Tuesday.

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Published by: Jeff Bair on Feb 28, 2012
Copyright:Attribution Non-commercial

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08/20/2013

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DISTRICTCOURT'",:,
INTIlEUNITEDSTATESDISTRICT
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DALLASDMSION
FEB232012
UNITED
STATESOFAMERICA
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JACQUESROY,
M.D.(1)
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STIGER
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WILBERTJAMESVEASEY,
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INDICTMENT'
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TheGrand
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charges:AtalltimesmaterialtothisIndictment,unless,otherwisespecified:
GeneralABegations
1.TheMedicareProgram("Medic~e")wasafederalhealthcareprogramprovidingbenefitstopersonswhowereovertheageof65ordisabled.MedicarewasadministeredbytheUnitedStatesDepartmentofHealthandHumanServices("HHS"),throughitsagency,theCentersforMedicare
&
MedicaidServices("CMS").IndividualsreceivingbenefitsunderMedicarewerereferredtoasMedicare"beneficiaries."2.TheTexasStateMedicaidprogram("Medicaid")wasafederallyandstatefundedprogramprovidingbenefitstoindividualsandfamilieswhometspecifiedfinancialandothereligibilityrequirements,andcertainotherindividualswholacked
1
 
adequateresourcestopayformedicalcare.CMSwasresponsibleforoverseeingtheMedicaidprograminparticipatingstates,includingTexas.3.MedicareandMedicaidwere"healthcarebenefitprograms,"asdefinedbyTitle18,UnitedStatesCode,Section24(b).4."PartA"oftheMedicareprogramcoveredcertaineligiblehomehealthcarecostsformedicalservicesprovidedbyahomehealthcareagency("HHA")tobeneficiariesrequiringhomehealthcareservicesbecauseofanillnessordisabilitycausing.themtobehomebound.PaymentsforhomehealthcaremedicalservicesunderMedicarePartAweretypicallymadedirectlytoaHHAorproviderbasedonclaimssubmittedtotheMedicareprogramforqualifyingservicesthathadbeenprovidedtoeligiblebeneficiaries,ratherthantothebeneficiary..5.Physicians,clinicsandotherhealthcareproviders,includingHHAsthatprovidedservicestoMedicarebeneficiaries,wereabletoapplyforandobtainaMedicare''providernumber."AhealthcareproviderthatwasissuedaMedicareprovidernumberwasabletofileclaimswithMedicaretoobtainreimbursementforservicesprovidedtobeneficiaries.AMedicareclaimwasrequiredtosetforth,amongotherthings,thebeneficiary'snameandMedicareidentificationnumber,theservicesthatwereperformedforthebeneficiary,thedatetheserviceswereprovided,thecostoftheservices,andthenameandidentificationnumberofthephysicianorotherhealthcareproviderthatorderedtheservices.
2
 
..
6.CMSdidnotdirectlypayMedicarePartAclaimssubmittedbyMedicare-'certifiedlllIAs.CMScontractedwithdifferentcompaniestoadministertheMedicarePartAprogramthroughoutdifferentpartsoftheUnitedStates.
In
theStateofTexas,eMScontractedwithTrailblazerHealthEnterprises("Trailblazer")toadministerPartAHHAclaims.Asadministrator,Trailblazerreceived,adjudicatedandpaidclaimssubmittedbY'HIlAprovidersunderthePart
A
programforhomehealthcareclaims.7.TheMedicareprogrampaid100%oftheallowablechargesforparticipatingHHAsprovidinghomehealthcareservicesonlyifthepatientqualifiedforhomehealthcarebenefits.Apatientqualifiedforhomehealthcarebenefitsonlyifthepatient:a.wasconfmedtothehome;alsoreferredtoashomebound;b.wasunderthecareofaphysicianwhospecificallydeterminedtherewasaneedforhomehealthcareandestablishedthePlanofCare("POC");andc.thedeterminingphysiciansignedacertificationstatementspecifyingthat:i.thebeneficiaryneededintermittentskillednursingservices,physicaltherapy,orspeechtherapy;ii.thebeneficiarywasconfmedtothehome;iii.aPOCforfurnishingserviceswasestablishedandperiodically.reviewed;andiv.theserviceswerefurnishedwhilethebeneficiarywasunderthecareofthephysicianwhoestablishedthePOCo8.MedicarePartAregulationsrequiredHHAsprovidingservicestoMedicare.patientstomaintaincompleteandaccuratemedicalrecordsreflectingthemedical
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