Hundreds of North Texas Nigerian-Americans are caught up in the biggest home health care frauds ever uncovered by U.S. law enforcement.

Federal indictments were issued in 2012 against those who allegedly profited the most from half a billion dollars in fraudulent local Medicare billings. But many other Nigerian-Americans living in the area and operating small health care businesses were also involved, federal law enforcement officials say.

Those officials say most of the health care fraud in Texas is committed by Texans with no particular ethnic background. And community leaders insist most Nigerian-Americans in the health care business in the Dallas area are honest.

But law enforcement officials and leaders in the Nigerian-American community describe Dallas home health care fraud as rampant and say a surprising number of the perpetrators — a third of all cases under investigation — involve Nigerian-Americans.

Dallas education consultant Remigus Ihekwaba said he and his wife looked at opening a home health care agency but changed their minds after sensing there was too much corruption.

“It is embarrassing to the Nigerian community that this type of thing is going on,” said Ihekwaba, who is also president of the West Africa America Chamber of Commerce and Industry in Dallas.

“It’s greed. Greed and trying to see the easy way out,” he said. “People took advantage of lax enforcement by the federal government on this issue.”

The FBI says health care fraud is the costliest crime in America. Estimates of the losses to federal health insurance programs like Medicare and Medicaid run from $44 billion to $80 billion a year.

Dallas has some of the highest Medicare spending in the nation. While the amounts spent on hospitals, drugs and doctors are not far off the national averages, home health care spending is far above the norm.

Dallas has some of the highest Medicare spending in the nation. Although the amounts spent on hospitals, drugs and doctors are not far off the national averages, home health care spending is far above the norm.

Medicare officials themselves say the business is rife with corruption.

“Our work with law enforcement has shown us that there is tremendous fraud going on, particularly with home health,” said Jon Blum, director of Medicare Services, during a June congressional hearing.

Unnecessary care

Between 2006 and 2012, federal law enforcement authorities allege more than 230 Dallas-area home health care agencies funneled patients to Arlington physician Joseph Megwa to approve $100.5 million in care they didn’t need. The owner of the largest home care agency in the case, Nigerian-American Ferguson Ikhile of Irving, has pleaded guilty.

Prosecutors and investigators say they have not tried to determine how many of the home health care groups that did business with Megwa are owned by Nigerian-Americans, and the list has not been made public.

Megwa, 59, came to Texas from Nigeria (after a sojourn in Australia) in 1998. His trial is scheduled to begin in April. He has pleaded not guilty.

Last month, Megwa’s attorneys asked the judge in the case to prohibit prosecutors from mentioning Megwa’s nationality or immigration status because of “a backlash in this country against immigrants, particularly immigrants of color and immigrants from Africa, who are charged with criminal offenses.”

Prosecutors countered that Megwa’s nationality is relevant to his travels and for explaining his relationships with witnesses and other defendants.

In a separate case, more than 500 Dallas-area home health care agencies are accused of sending patients to Rockwall physician Jacques Roy for fraudulent treatments worth $374 million.

Nigerian-American Cyprian Akamnonu of Cedar Hill, who owned the largest agency working with Roy, has pleaded guilty. He was sentenced to 10 years in prison and ordered to repay more than $25 million.

Roy, who is originally from Montreal, is scheduled to stand trial in June. Denied bail as a flight risk, he has maintained his innocence at the Seagoville Federal Correctional Institution.

In each case, Nigerian-American caregivers sent the doctors phony therapy plans for thousands of elderly patients. Some of the elderly had no idea what was happening, but others were bribed with food stamps or gift cards to go along with the scheme — including Medicare beneficiaries at the Bridge homeless shelter in Dallas.

Prosecutors allege the doctors signed off on the plans, sometimes without ever seeing the patients, for a share of the proceeds.

Several other cases involving Nigerian-Americans in smaller home health care frauds are wending their way through the criminal justice system in Dallas and Houston.

Misunderstandings

Godson Anyanwu, a Nigerian-American attorney in Dallas who has worked with many health care firms, said both lax regulation and ignorance of the law were behind the high numbers of Nigerians caught up in fraud.

“Earlier, in the mid-1990s, Medicare paid any bill submitted to them before checking it. So many people, for that reason, sent them any bill, and now things are changing. Some of the people being charged don’t understand the fundamentals of Medicare,” he said.

“In home health care, they did not understand that you have to be homebound. Honestly, they do not understand that if you can walk out of the house, you do not qualify,” he said.

“That’s why the numbers involved are so enormous.”

But Anyanwu and other community leaders resent the emphasis on Nigerian involvement with health care fraud. There is a fundamental tension involved in trying to describe a crime wave perpetrated by members of an ethnic group without making the description an ethnic slur.

“With health fraud, my philosophy is, if you commit the crime, you pay for that. But when hospitals steal billions, nobody goes to prison. The mom and pop home health people do,” Anyanwu said. “Is it an embarrassment for us? Yes. Should we publicize it? Yes.”

Fifty years ago, Italian Americans were upset by the focus of law enforcement and the media on the Mafia as the face of organized crime in America.

Three former federal prosecutors from the Obama administration say this is now happening with health care fraud. Russians, Cubans, Armenians, Vietnamese and, in Texas, Nigerians are scamming Medicare for billions of dollars. These prosecutors, including Jeremy Sternberg of Boston, say the scams are attractive to ethnic criminal groups because they’re easy, low risk and lucrative.

“Health care fraud is where the money is, and the sentences are lighter than what they face for gambling, drug trafficking and racketeering,” he said.

Louis Saccoccio, CEO of the National Health Care Anti-Fraud Association, described it this way.

“If you’re organized crime, and you’re looking to get into something that’s going to make you a lot of money where people aren’t going to shoot at you, it’s a perfect place to go,” he said.

Ethnicity not an issue

While Miami may be plagued with Cuban-American fraud rings, and Los Angeles by Armenian gangs, the Nigerians involved in frauds in Dallas and Houston don’t fit the organized crime profile.

U.S. Attorney Sarah Saldaña said the large number of Nigerians involved in North Texas Medicare fraud cases was unimportant from a prosecutor’s standpoint.

“Where they come from carries no weight in any of the indictments I am aware of,” she said. “It’s not material, not significant to a jury.”

Texas Attorney General Greg Abbott’s office hasn’t focused on Nigerians involved in Medicaid fraud, either, even though West African surnames account for about one in three of those arrested under investigations directed by his office.

Mike Fields, special agent in charge in Dallas with the inspector general’s office of the U.S. Department of Health and Human Services, said the Nigerians involved in fraud cases tend to be well educated and willing to share techniques and even patients with each other.

But they aren’t working as members of a larger criminal enterprise, he said.

Those sending money back to Nigeria are helping family rather than paying a crime boss, Fields said. “We’ve partially subsidized Nigeria with Medicare funding.”

The frauds against Medicare — whether for home health care, durable medical equipment or ambulance services — have been easy to commit.

A Sugar Land concert promoter, cellphone store owner and medical equipment supplier named Aghaegbuna “Ike” Odelugo told a congressional committee in 2011 he figured out a way to defraud Medicare in “less than a month.”

“All of this is right in the computer,” he said. “You go online, you can see them [medical equipment descriptions] and how much they pay for it. And you get the correct code and bill it. That is all it takes.”

Odelugo pleaded guilty to health care fraud and was sentenced to six years in prison. He was also ordered to repay the government $9.9 million.

Biggest fraud

Health care fraud committed by Nigerian-Americans in Houston and Dallas has involved billing the government for power wheelchairs when ordinary wheelchairs or walkers were provided, or billing for the most expensive knee braces and orthopedic kits when cheaper ones were used.

Others have gone to prison for billing Medicare after providing ambulances for people who were able to walk or drive themselves.

In Dallas, home health care has been by far the biggest fraud alleged by federal authorities.

Home care usually involves helping the elderly with the chores of living that they can no longer do themselves. This is called long-term care.

Medicare doesn’t pay for it.

Generally, Medicare pays for care by therapists working with seniors just out of the hospital who need help to get back on their feet. The care has to be rehabilitative, not custodial.

In the Megwa case, Ikhile has told investigators that he sent the names of his patients at PTM Healthcare Services to Megwa to have him certify they were eligible for Medicare-funded rehabilitation. Megwa allegedly signed plans of care for these patients written by Ikhile in return for payoffs. Once a 60-day term of care was over, the process was repeated.

The arrangement lasted five years, until November 2011.

Megwa owned Raphem Medical Practice in Arlington. When a co-worker tried to attach medical charts to the care plans Megwa was signing, he allegedly waved him off, saying the effort was tiring his wrist, according to the indictment.

Ihkile’s home health care agency was just one of the agencies that referred about 2,000 patients to Megwa between 2006 and 2011. Federal prosecutors allege that Megwa signed more than 33,000 care plans for these patients, some of them while traveling in Nigeria and others after shifting his practice to Fresno, Calif.

Apart from Ikhile, none of the other agency owners was indicted in the case. Ebolose Eghobor, a Nigerian-Canadian who was director of nursing for PTM, was indicted along with Ikhile. When Medicare audited PTM in 2010, it determined many of the patients were not homebound and weren’t eligible for Medicare treatments. Eghobor then allegedly prepared fraudulent care plans for patients recruited by other home health care agencies.

Eghobor has pleaded not guilty.

Caregivers not indicted

Megwa, Ikhile and Eghobor were indicted seven months after Roy and his confederates. Hardly any of the home caregivers who were using Megwa and Roy to certify their patients for Medicare money were indicted. But many have sought lawyers.

Dallas attorney Anyanwu said several came to him.

Investigators say they are auditing the billings of the unindicted agencies with the intent of recovering at least some of the money.

In the criminal cases, many of the patients themselves were breaking the law. The home care agencies needed Medicare beneficiaries’ IDs to bill the government. So they would send out recruiters offering companionship, food stamps, cash and gift cards. Roy’s indictment alleges a nurse went to the Bridge homeless shelter to recruit Medicare beneficiaries for home health care.

“They target seniors living in poor neighborhoods,” said Mike Fields, the special agent. “The recruiters are local and well connected with local churches and community centers. They find people who wouldn’t have ever considered home health care, and $100 a month makes a huge difference in their lives.”

When Jacques Roy was indicted early in 2012, U.S. Deputy Attorney General James Cole characterized the physician as the ringleader.

“The conduct charged in this indictment represents the single largest fraud amount orchestrated by one doctor in the history of … our Medicare Fraud Strike Force operations,” he said.

Fields said the physicians involved with home health care frauds aren’t necessarily the ones running the show. “The agencies are more likely to seek them out,” he said. “Once word gets out that a doctor’s willing, everyone seems to use him.”

Akamnonu, the Cedar Hill resident, was ordered to repay $25,466,779 after pleading guilty to one count of conspiracy to commit health care fraud. Akamnonu, 64, and his wife, Patricia, owned Ultimate Care Home Health Services in Arlington. Both were arrested last year and accused of colluding with Dr. Roy.

Patricia Akamnonu allegedly used food stamps and promises of free care to recruit seniors who did not need Medicare’s home benefits. She has pleaded not guilty and is scheduled for trial along with Roy in June.

Igbo tribe

Home health care has proved attractive to immigrants in Dallas from Nigeria’s Igbo tribe. The largely Christian Igbo hail from southeastern Nigeria. There are tens of thousands of Igbo — perhaps as many as 50,000, local leaders say — living in the Dallas area.

More than a dozen of them have been indicted for fraud by federal prosecutors, raising complaints from some that the government is unfairly targeting the Igbo community.

Richard Nwachukwu, publisher of the Dallas-based Africa Herald newspaper, argues that many of the prosecutions involve innocent errors of paperwork or a lack of awareness of federal regulations.

“Any small change and you will be accused of fraud,” he said. “And there are so many charged for one mistake! If the government targets you, they can find anything.

“There are lots of Igbo who own home health agencies — a couple of hundred of them,” he said. “They are not in trouble. They are doing it the right way.”

U.S. Attorney Saldaña said Medicare’s laws and regulations make clear what is allowed.

Unlike other immigrants who congregate in enclaves, these Nigerian-Americans live and work throughout the area. For some, assimilation is complete. Two of Megwa’s nephews, for instance, are NFL linebackers.

The Nigerian roots of these immigrants come out when they gather socially. There are more than 50 tribal groups in North Texas, such as the Igbo Community Association of Nigeria DFW and the Owerri Peoples Association DFW. Ernest Amadi, who was convicted of health care fraud in late 2011, was a member of the Igbo Community Association’s board of directors.

The groups host birthdays, weddings and holiday balls. The dress at these parties is formal, colorful and tribal. Many of the women wear satin scarves wound high above their heads. The men pay strict attention to the titles and trappings of tribal or church office, such as Sir or Chief. There are two Ezes, or kings, living in the Dallas area.

The associations also host business luncheons where guest speakers have discussed home health care. Law enforcement officials say they suspect that fraud schemes and techniques have been shared as table talk at these networking events.

In one Powerpoint presentation about home health care at an association luncheon, the consultant put up a slide describing how a business should respond if raided by federal anti-fraud authorities.

Biafra war

Eddie Osuagwu, 52, is a Dallas mental health counselor and an honorary Igbo chief. He knows what investigators are saying about the associations and feels they are unfairly maligning ordinary networking.

Osuagwu said many Nigerians like him came to Texas to go to inexpensive colleges. After getting three degrees in the 1980s from what is now Texas A&M University-Commerce, Osuagwu said going back to Nigeria was not an option.

“The government of Nigeria became so ruthless and selfish, there were no opportunities for the well-educated,” he said.

From 1967 to 1970, the Igbo tried to secede from Nigeria and create an independent state in the southeast called Biafra. In the resulting civil war, as many as 3 million people died, most due to starvation and disease.

Osuagwu’s father was a local leader in the Biafran struggle and was responsible for recruiting soldiers into the Biafran army. After the war was lost, angry parents shot and killed him in front of 10-year-old Eddie.

The Biafra war sent waves of Igbo abroad.

For many of these émigrés, opportunities in Texas that seemed strong from a distance were less so when experienced firsthand. Osuagwu said he had some disappointing experiences before striking out on his own in 1996.

“Business has not been great, but it is rewarding to help people,” he said.

Anyanwu, the Igbo attorney in Dallas, said Nigerians go into home health care because it offers a chance to get ahead that is otherwise hard to find.

“Say there is a cab driver with five children, or someone who takes a job at the jail paying $35,000 or $40,000,” he said. “Eventually his wife becomes a nurse. They may decide, ‘If we open a home health agency, we can own our own business.’ It’s not with the intent to commit fraud.”

But the lure of easy, illicit money has swayed several area residents of Igbo descent.

A University of Nigeria lawyer and historian, Ihediwa Nkemjika Chimee, theorizes that the Biafra war and its aftermath crushed the traditional ethics and moral values of some Igbos. Corruption has plagued Nigeria for decades, from the highest to lowest levels of government.

The Igbo have been largely kept out of this corrupt top echelon. Instead, they’ve been discriminated against by the victors in the Biafra war. For Igbos forced to pay bribes for the most basic services, the experience has bred cynicism.

“Those in the diaspora that have taken to criminality do so in response to the moral state of the society, and one is not surprised,” Chimee wrote in an email. “For some of them, without material success, there is no basis to justify their being outside the shores of Nigeria.”

Osuagwu isn’t buying it.

“Forty years is surely enough time to come back to your moral and ethical values,” he said.

Follow Jim Landers on Twitter at @landersjim.

AT A GLANCE: Home health care and fraud

In 2010, a special audit of the 11,203 home health care agencies licensed to do business with Medicare found that 1 in 4 had questionable billing indicating fraud. Of that group, 1,000 were in Texas, representing 45 percent of all the agencies in the state.

After the 2012 special audit, a moratorium on new home health care agency licenses in Texas was recommended by the Office of Inspector General for the federal Department of Health and Human Services’ office of inspector general.

The moratorium was put in place in January in Dallas and Houston. In July, the agency slapped a moratorium on new ambulance services in Houston.

In 2011, 13 of the 25 counties with the highest use of home health care were in Texas, including a third of all Medicare beneficiaries in Duval, Brooks and Jim Hogg counties.

In 2011, Medicare spent an average of $1,624 on home health care for each beneficiary in Dallas County. The national average was $546.

SOURCES: Office of the Inspector General, U.S. Department of Health and Human Services; Medicare Payments Advisory Commission; Centers for Medicare and Medicaid Services