More on Compliance & Legal

Texas doctor slapped with 35-year sentence and $268M in restitution for massive fraud scheme

The Department of Justice said the elaborate fraud scheme "takes brazen to a whole new level."

Beth Jones Sanborn, Managing Editor

A 60-year-old Dallas-area doctor will spend decades in prison and pay more than $268 million dollars in restitution after being convicted of conspiracy and healthcare fraud charges as well as obstruction of justice for a scheme that bilked Medicare and Medicaid for hundreds of million of dollars.

For what the Department of Justice called a "large-scale, sophisticated healthcare fraud scheme," physician Jacques Roy, was sentenced last week to 35 years in prison along with the hefty restitution penalty, for conspiring with several co-defendants to defraud Medicare and Medicaid through companies they owned, including Medistat Group Associates, Apple of Your Eye Health Care Services, Ultimate Care Home Health Services and Charry Home Care Services.

Some of them improperly recruited Medicare to sign up for home health care services, including individuals from a Dallas homeless shelter and were paid $50 per beneficiary. Medical documents were falsified to make the beneficiaries appear to qualify for such services which in fact were not medically needed, and "plans of care" were certified under Dr. Roy's direction without proper evaluation by a physician, the DOJ said, however, the paperwork indicated Dr. Roy had signed off on the plans.

HIMSS20 Digital

Learn on-demand, earn credit, find products and solutions. Get Started >>

The services were only allowed for homebound patients in need of skilled nursing services. "This process was repeated for thousands of POCs, and, in fact, Medistat's office included a "485 Department," essentially a "boiler room" to affix fraudulent signatures and certifications."

[Also: Running list of notable 2017 healthcare frauds]

The DOJ said falsified visit notes created the appearance that services were being rendered and weren't necessary. Roy would also visit patients, perform home visits that weren't needed, and then order unnecessary services for the beneficiaries.

Medistat processed and approved POCs for 11,000 beneficiaries from more than 500 different home health agencies, and submitted fraudulent claims for the certifications, recertifications, and unnecessary medical services totaling the DOJ said.

The obstruction of justice conviction stems from Roy's actions following the Centers for Medicare and Medicaid Services suspending him and Medistat from receiving Medicare payments after June 2, 2011, due to suspected fraud. Roy then went through another company, Medcare House Calls, to have the medical providers he employed be re-credentialed and to bill Medicare under that company instead of Medistat. The Medicare reimbursements were filtered back to Medistat and Dr. Roy.

"The only thing more stunning than Jacques Roy and his co-conspirators' shameless methods," said U.S. Attorney John Parker, "is the staggering dollar amounts involved in this fraud scheme. This takes brazen to a whole new level."

Twitter: @BethJSanborn