Clinical Director of Home Care Agency Convicted of Health Care Fraud Scheme
BOSTON—The clinical director of a home nursing agency was convicted today in U.S. District Court in Boston following a four-day trial in connection with her role in a multi-million dollar scheme to defraud Medicare.
Janice Troisi, 66, of Revere, was convicted of conspiracy to commit health care fraud and 10 counts of health care fraud. U.S. District Court Judge Douglas P. Woodlock scheduled sentencing for Nov. 10, 2015.
Troisi, a registered nurse, was the Clinical Director of At Home VNA (AHVNA), a home health agency located in Waltham, which was owned and operated by her co-conspirator, Michael Galatis, also a registered nurse. From 2006 to 2012, Galatis submitted more than $27 million in fraudulent home health care claims to Medicare, and Medicare paid more than $20 million of those fraudulent claims that, by and large, were not medically necessary. Troisi joined AHVNA in fall 2009, and by Jan. 1, 2010, she had joined the conspiracy.
The Medicare program pays for home health services only under specified conditions, including that a physician has certified that the patient is homebound and needs certain skilled services, such as nursing or physical therapy. Troisi and Galatis trained AHVNA nurses to recruit Medicare beneficiaries who lived in senior housing developments or group homes for the disabled. They held “wellness clinics” at these developments, where nurses convinced senior citizens to enroll with AHVNA and have a nurse visit them in their home. Troisi and Galatis trained AHVNA nurses to manipulate the patients’ Medicare assessment forms to make it appear as though the patients qualified for Medicare home health services, when that was often not the case. The home health orders were signed by AHVNA’s paid medical director, Dr. Spencer Wilking. Dr. Wilking falsely certified to Medicare that these individuals were homebound and needed skilled services, when he never treated or even met the vast majority of AHVNA’s approximately 1,400 patients. In fact, the overwhelming majority of AHVNA’s patients were not homebound and did not need home health services, but many worked, took out-of-state vacations, and lived independent lives.
Many of the patients’ primary care physicians were unaware that AHVNA was sending nurses to see their patients in their homes. A number of primary care physicians who learned of AHVNA’s services complained to Troisi and Galatis and asked them to stop seeing their patients, but Troisi and Galatis ignored these requests. Similarly, AHVNA’s nurses frequently asked Troisi and Galatis if they could stop seeing the patients, because they did not need home health services, but Troisi and Galatis refused these requests as well in order to ensure a steady billing stream.
In 2011, Medicare passed a new regulation requiring that the physician certify that she or he had a face-to-face encounter with the patient about the need for home health care. Even after this regulation was enacted, Troisi continued to prepare certifications and orders for home health care for a doctor to sign despite knowing that the doctor had not examined any of the patients. This allowed Galatis to bill Medicare for millions of dollars of home health care despite the new regulation.
Galatis was convicted of conspiracy to commit health care fraud, ten counts of health care fraud, and seven counts of money laundering, and sentenced in February 2015 to 92 months in prison.
The charging statutes each provide a sentence of no greater than 10 years in prison, three years of supervised release, a fine of $250,000 or the greater of twice the gross gain or loss resulting from the offense, and restitution to the Medicare program. Actual sentences for federal crimes are typically less than the maximum penalties. Sentences are imposed by a federal district court judge based upon the U.S. Sentencing Guidelines and other statutory factors.
United States Attorney Carmen M. Ortiz; Philip Coyne, Special Agent in Charge of the Department of Health and Human Services, Office of Inspector General, Office of Investigations; Vincent B. Lisi, Special Agent in Charge of the Federal Bureau of Investigation, Boston Field Division; and William P. Offord, Special Agent in Charge of the Internal Revenue Service’s Criminal Investigation in Boston, made the announcement today. Assistance was also provided by the New England Benefit Integrity Support Center, a fraud contractor for the Medicare program. The case was prosecuted by Assistant U.S. Attorneys Lisa A. Schlatz and David S. Schumacher of Ortiz’s Health Care Fraud Unit.