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Jacques Roy, M.D., et al, Medicare/Medicaid raud Indictment - 02-28-2012

Jacques Roy, M.D., et al, Medicare/Medicaid raud Indictment - 02-28-2012

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Published by mfb1949
This is the indictment o Dr. Jacques Roy and six others describing what has been alleged as the worst Medicare/Medicaid fraud ever.
This is the indictment o Dr. Jacques Roy and six others describing what has been alleged as the worst Medicare/Medicaid fraud ever.

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Published by: mfb1949 on Mar 01, 2012
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03/01/2012

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INDICTMENT'
TheGrandAtalltimesmaterialtothisIndictment,unlessotherwisespecified:
GeneralAllegations
1.TheMedicareProgram("MedicE\.re")wasafederalhealthcareprogramprovidingbenefitstopersonswhowereovertheageof65ordisabled.MedicarewasadministeredbytheUnitedStatesDepartmentofHealthandHumanServices("HES").throughitsagency,theCentersforMedicare
&
MedicaidServices("CMS").IndividualsreceivingbenefitsunderMedicarewerereferredtoasMedicare"beneficiaries."2.TheTexasStateMedicaidprogram("Medicaid")wasafederallyandstate.~.'fundedprogramprovidingbenefitstoindividualsandfamilieswhometspecifiedfinancialandothereligibilityrequirements,andcertainotherindividualswholacked
 
adequateresourcestopayformedicalcare.CMSwasresponsibleforoverseeingtheMedicaidprograminparticipatingstates,includingTexas.3.MedicareandMedicaidwere"healthcarebenefitprograms,"asdefinedbyTitle18,UnitedStatesCode,Section24(b).4."PartA"oftheMedicareprogramcoveredcertaineligiblehomehealthcarecostsformedicalservicesprovidedbyahomehealthcareagency("HHA")tobeneficiariesrequiringhomehealthcareservicesbecauseofanillnessordisabilitycausingthemtobehomebound.PaymentsforhomeheaithcaremedicalservicesunderMedicarePartAweretypicallymadedirectlytoaHHAorproviderbasedonclaimssubmittedtothe'Medicareprogramforqualifyingservicesthathadbeenprovidedtoeligiblebeneficiaries,rathertha.ntothebeneficiary.'5.Physicians,clinicsandotherhealthcareproviders,includingHHAsthatprovidedservicestoMedicarebeneficiaries,wereabletoapplyforandobtainaMedicare"providernumber."AhealthcareproviderthatwasissuedaMedicareprovidernumberwasabletofileclaimswithMedicaretoobtainreimbursementforservicesprovidedtobeneficiaries.AMedicareclaimwasrequiredtosetforth,amongotherthings,thebeneficiary'SnameandMedicareidentificationnumber,theservicesthatwereperformedforthebeneficiary,thedatetheserviceswereprovided,thecostoftheservices,andthenameandidentificationnumberofthephysicianorotherhealthcareproviderthatorderedtheservices.
2
 
6.CMSdidnotdirectlypayMedicarePartAclaimssubmittedbyMedicare-certifiedHHAs.CMScontractedwithdifferentcompaniestoadministertheMedicarePartAprogramthroughoutdifferentpartsoftheUnitedStates.
In
theStateofTexas,CMScontractedwithTrailblazerHealthEnterprises("Trailblazer")toadministerPartAHRAclaims.Asadministrator,Trailblazerreceived,adjudicatedandpaidclaims..submittedby-HHAprovidersunderthePartA.programforhomehealthcareclaims.7.TheMedicareprogrampaidlOO%oftheallowablechargesforparticipatingHHAsprovidinghomehealthcareservicesonlyifthepatientqualifiedforhomehealthcarebenefits.Apatientqualifiedforhomehealthcarebenefitsonlyifthepatient:a.wasconfinedtothehorne,alsoreferredtoashomebound;b.wasunderthecareofaphysicianwhospecificallydeterminedtherewasaneedforhomehealthcareandestablishedthePlanofCare("POe");andc.the"determiningphysiciansignedacertificationstatementspecifyingthat:
1.
thebeneficiaryneededintermittentskillednursingservices,physicaltherapy,orspeechtherapy;
11.
thebeneficiarywasconfinedtothehome;
111.
apoeforfurnishingserviceswasestablishedandperiodically.reviewed;andiv.theserviceswerefurnishedwhilethebeneficiarywasunderthecareofthephysicianwhoestablishedthepoe.8.MedicarePartAregulationsrequiredHHAsprovidingservicestoMedicarepatientstomaintaincompleteandaccuratemedicalrecordsreflectingthemedical
3

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