Tennessee Federal Criminal Lawyer Blog

The Federal Government is continuing its crackdown on Medicare fraud. According to a recent article in the Insurance Journal, a physician, his office manager, and five owners of home health agencies were arrested after allegedly committing health care fraud totaling nearly 375 million dollars in Dallas, Texas.

These charges come after investigations conducted by the Medicare Fraud Strike Force, a division of the Health Care Fraud Prevention and Enforcement Action Team (HEAT). According to the investigation, Dr. Jacques Roy owned and operated a practice that certified or directed the certification of more than 11,000 individual patients from more than 500 home health agencies (HHA). During its five-year stint, Dr. Roy's practice certified more Medicare beneficiaries for home health services and had more patients than any other medical practice in the United States. According to the indictment, the fraudulent activity caused more than $350 million dollars to be erroneously billed to Medicare and more than 24 million dollars to be fraudulently billed to Medicaid by Dr. Roy and the HHAs associated with his practice.

Dr. Roy and the HHAs with whom he allegedly conspired with were caught due to suspicious billing spikes tracked by the Health and Human Services (HHS). While a vast majority of physicians who certified patients for home health only signed off on 104 or fewer patients in the year 2010, Dr. Roy certified more than 5,000 patients in that year alone.

The federal government has recently been cracking down health care fraud due to its belief that such fraud not only increases costs for consumers, taxpayers, and health insurance plans; it also victimizes the elderly and disadvantaged. Since 2007, the Medicare Fraud Strike Force has charged more than 1,190 defendants who have collectively charged the Medicare program more than 3.6 billion dollars. So to send a clear message to other potential physicians thinking about committing healthcare fraud, Dr. Roy and his fellow conspirators each face up to ten years in prison and a $250,000 fine for each count of conspiracy as well as a maximum penalty of five years in prison and a $25,000 fine for each false statement charged against them. Seventy-eight additional HHAs associated with Dr. Roy have also been suspended by the Centers for Medicare & Medicaid Services (CMS) based on allegations of fraud against them.

Medicaid fraud defense attorneys will be among the first to tell you that federal prosecutors are becoming more active in pursuing alleged healthcare fraud, particularly as it relates to Medicaid Fraud. As it turns out, the Government is reaping the financial benefits of their efforts.

According to an article in USA Today, the Federal Government made over $1.85 billion in Medicaid fraud prosecutions in 2010. This is triple the amount gained in 2004, where the Federal Government made only $573 million.

Medicaid is a state program that uses federal funds to assist children, pregnant woman, disabled, and elderly patients who need medical care but fall below the poverty line. However, a growing number of medical providers have found ways to bill their respective state programs for services that were either underperformed or not performed at all. To help combat this fraudulent behavior, the Obama Administration created certain programs and regulations while passing the new health care law.

For example, all medical professionals who provide health care for Medicaid patients are now required to keep electronic records. This requirement enables law enforcement to more successfully catch possible fraudulent activity. Also, private Medicaid contractors who audit health care clinics are now required to report any potential fraudulent activity to enforcement agencies. The Federal government has also sent more resources to high-fraud states like Florida and Texas to help with investigations and better catch fraudulent behavior.