Here is a story from Home Health Care News about one who got caught, but not before perpetrating nearly $375 million in health care fraud.
April 17, 2016
A Dallas physician and three home health agency owners have been found guilty of committing the nation’s largest home health care fraud involving a single doctor.
Jacques Roy, a 58-year-old physician from Rockwall, Texas, and three owners of Texas home health agencies—Cynthia Stiger of Dallas, Wilbert James Veasey, Jr. of Dallas and Charity Eleda of Rowlett—were found guilty on April 13 of conspiracy to commit health care fraud, stemming from their roles in an almost $375 million health care fraud scheme, the Department of Justice announced.
Roy, Veasey, Stiger and Eleda were each convicted by a federal jury on one count of conspiracy to commit health care fraud. Additionally, Roy was convicted on eight counts of health care fraud, two counts of making a false statement relating to health care matters and one count of obstruction of justice.
Veasey and Eleda were convicted on three and four counts of health care fraud, respectively, and Eleda was also convicted on three counts of making false statements for use in determining rights of benefit and payment by Medicare.
Roy has been in federal custody since his arrest on February 28, 2012. He owned and operated Medistat Group Associates, P.A., an association of health care providers that provided home health certifications and conducted home visits with patients. Veasey and Stiger, who owned and operated Apple of Your Eye Healthcare Services, Inc., and Eleda, who owned and operated Charry Home Care Services, Inc., were arrested on charges in the same indictment as Roy.
During the six-week-long trial, the government presented evidence that Roy, Veasey, Stiger and Eleda engaged in a large-scale, sophisticated health care fraud scheme during which they schemed together and with others to defraud Medicaid and Medicare through agencies they controlled or owned.
Veasey, Stiger and Eleda, as part of the conspiracy, worked with others to improperly recruit people with Medicare coverage to sign up for Medicare home health care services, the DOJ said. Eleda recruited patients from a homeless shelter in Dallas, at times paying recruiters $50 per beneficiary they found and directed to her car parked beyond the shelter’s gates. Eleda and other nurses would falsify medical documents to make it seem as though those beneficiaries qualified for home health care services that were actually medically unnecessary. Eleda and the nurses also prepared Plans of Care (POC) that were not medically necessary, and these POCs were delivered to Roy or a different doctor working under his direction at Medistat.
Roy, then, instructed his staff to certify these POCs, which indicated to Medicaid and Medicare that a physician, usually Roy, had reviewed the treatment plan and found it medically necessary. That certifying doctor, usually Roy, certified that the patient needed home health services, which were only allowed to be provided to those individuals who were homebound and required skilled nursing, among other things. This process was repeated for thousands of POCs, and Medistat’s office actually had a “485 Department,” essentially a “boiler room” to affix fraudulent certifications and signatures, the DOJ said.
Once an individual was wrongly certified for home health care services, Eleda, nurses who worked for Veasey and Stiger, and other nurses falsified visit notes to make it seem as though skilled nursing services were being provided and remained necessary. Roy would also visit the patients, perform unnecessary home visits, and then order medically unnecessary services for the recruited beneficiaries. Then, under Roy’s orders, Medistat employees would submit fraudulent claims to Medicare for the certification and recertification of unnecessary home health care services and additional unnecessary medical services.
The scope of Roy’s fraud was huge: Medistat processed and approved POCs for 11,000 unique Medicare beneficiaries from over 500 different home health agencies, the DOJ said. Roy entered into informal and formal fraudulent arrangements with Charry, Apple, Ultimate and other home health agencies to guarantee his fraudulent business model worked and that he maintained a steady stream of Medicare beneficiaries.
Sentencings for those found guilty are scheduled for this fall, the DOJ said. Each health care fraud and conspiracy count carries a maximum statutory penalty of 10 years in federal prison and a $250,000 fine. The obstruction of justice count and each false statement count carry a maximum statutory penalty of five years in federal prison, as well as a $250,000 fine.
Three additional defendants who had been charged in the case—Cyprian Akamnonu and his wife, registered nurse Patricia Akamnonu, and Teri Sivils—each pleaded guilty before trial to one count of conspiracy to commit health care fraud. Sivils, who was the office manager at Medistat, pleaded guilty in April 2015, and is expected to be sentenced in June. Cyprian and Patricia Akamnonu, who owned Ultimate Care Home Health Services, Inc., are now each serving a 10-year federal prison sentence. They were also ordered to pay a $25 million fine.