What is Medicare Fraud?

Medicare fraud occurs when a hospital, nursing home, doctor's office, hospice care facility, ambulance service, pharmacy, rehabilitation center, or any other type of healthcare provider overbills Medicare.


Who can report Medicare fraud?

Medicare fraud whistleblowers are almost always healthcare professionals. They are commonly employed as hospital administrators, nurses, hospice or nursing home workers, ambulance drivers, pharmacists, or as any other type of healthcare professionals.

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Physician and Six Others Linked To Huge $375 Million Medicare Scheme
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Seven people, including a doctor and his office manager, were arrested for allegedly making fraudulent claims as part of a Medicare scheme. The damage nears $375 million.
The charges were brought about by Deputy Attorney General James Cole and members of other groups, including Health and Human Services, the Justice Department’s Criminal Division, FBI and Centers for Medicare and Medicaid Services.

The physician, Jacques Roy, M.D., is a 54-year-old from Rockwall, Texas charged with nine counts of substantive health care fraud. Roy and six others are charged with one count each of conspiracy to commit health care fraud. Others involved in the scheme are charged with health care fraud and making false statements to Medicare. Aside from this group of people, several home health agencies associated with the physician have been suspended. The conspiracy charge and health care fraud charges carry possible a penalty of 10 years in prison. The false statement charge faces a maximum of five years in prison. Each of these charges also comes with a $250,000 fine.

These charges come after development of tools specifically designed to detect instances of fraud and similar schemes. The Medicare Fraud Strike Force was designated to look into leads involving Medicare fraud. The group was led to Roy after he allegedly certified at least 11,000 patients from several different home health agencies in just five years. In this period of time he certified more patients for Medicare than any other practice in the country. As a result, nearly $375 million were billed to either Medicaid or Medicare. The group claims this is the largest scheme related to home health fraud, if the allegations are proven to be true. Roy is also accused of making unnecessary visits to patient homes and providing services that were not needed to begin with.

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