Home Health Care Scam
BOSTON - The former medical director of a Waltham-based home health agency pleaded guilty today for his role in a home health fraud scheme which cost Medicare over $27 million.
Dr. Spencer Wilking, 65, of Concord, pleaded guilty today before U.S. District Judge Joseph L. Tauro to health care fraud. Sentencing is scheduled for May 20, 2014. The statutory maximum penalty for the crime is 10 years in prison, three years of supervised release, a fine of $250,000 or twice the gross loss to the Medicare program or twice the gross gain to Wilking (whichever is greater), restitution to Medicare, forfeiture of any proceeds of the offense, and exclusion from the Medicare program.
From at least April 2011 through March 2012, Wilking was employed as the Medical Director for MJG Management Company, d/b/a At Home VNA (AHVNA), a home health agency located in Waltham. During this period, Wilking signed certifications and recertifications to provide AHVNA home health services to hundreds of Medicare beneficiaries who did not qualify for services under the Medicare program. To qualify for home health services under the Medicare program, the beneficiary had to be: (1) confined to his/her home, (2) in need of skilled nursing services, physical therapy, or speech therapy on an intermittent basis or occupational therapy on a continuing basis, and (3) under the care of the physician who established the plan of care for home health services.
Prior to initially certifying eligibility, Wilking had to document that he, or another qualified health care provider, had a “face-to-face encounter” with the beneficiary, which showed that the patient was homebound and in need of home health services. Despite these legal requirements, Wilking certified hundreds of Medicare beneficiaries for home health services by AHVNA, without conducting a “face-to-face encounter” with the beneficiary, the vast majority of whom were not referred to AHVNA by their primary care physician or another physician who had examined the patient. Instead, Wilking typically certified services after spending a minimal amount of time reviewing patient assessment forms that were prepared by AHVNA nurses and/or participating in brief discussions about the patients with the nurses and/or AHVNA’s Clinical Director, Janice Troisi. Had Wilking reviewed the patient files, he would have discovered that many of the files contained information demonstrating that many of the patients were not homebound because, for example, they worked, took vacations, and spent substantial time outside the home. The patient files also contained information demonstrating that many patients had not requested home health services and/or were not provided with skilled nursing services.
Wilking’s certifications and recertifications allowed AHVNA to bill Medicare Part A for payment for these home health services. In addition, Wilking, billed Medicare Part B for both the certifications and subsequent recertifications. During the relevant time period, Medicare paid AHVNA over $1 million for the services certified by Wilking where the patients had not had the required face to face encounter with a physician. In addition, during the same period, Medicare paid nearly $30,000 to Wilking for certifying and recertifying the patients. Finally, between April 2011 and April 2012, AHVNA paid Wilking approximately $42,000 to serve as the company’s medical director.
In September 2013, the owner of AHVNA Michael Galatis, 62, of Natick and the Clinical Director, Janice Troisi, 64, of Revere, were charged with conspiracy to commit health care fraud and 11 counts of health care fraud. Galatis was also charged with seven counts of money laundering. According to the indictment, between 2007 and 2012, Galatis and Troisi conspired to fraudulently induce the Medicare program to pay for home health care services that, by and large, the Medicare beneficiaries did not need nor want. They trained AHVNA nurses to recruit Medicare beneficiaries who lived in residential facilities for senior citizens by asking if they were insured by Medicare, and if so, if they would like to have a nurse visit them in their home. The indictment also alleges that they trained the nurses to manipulate the patients’ initial assessments to make it appear as though the patients qualified for home health services pursuant to Medicare’s guidelines, when that was often not the case. The home health certifications and plans of care were then signed by Wilking, who certified that the patients were homebound and in need of skilled services, when, in fact, the overwhelming majority of AHVNA’s patients were not homebound and did not need home health services. During the course of the conspiracy, AHVNA submitted more than $27 million in false and fraudulent claims to Medicare, and Medicare paid AHVNA more than $20 million.
Both Galatis and Troisi have entered not guilty pleas. If convicted, they each face up to 10 years in prison, three years of supervised release, a $250,000 fine or twice the gross loss to the Medicare program or twice the gross gain to the defendant (whichever is greater), restitution to Medicare, forfeiture of any proceeds of the offenses, and exclusion from the Medicare program.
The defendants are presumed innocent unless and until proven guilty beyond a reasonable doubt in a court of law.
United States Attorney Carmen M. Ortiz; Phillip 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; and William P. Offord, Special Agent in Charge of the Internal Revenue Service’s Criminal Investigation in Boston, made the announcement today. The case is being prosecuted by Assistant U.S. Attorneys David S. Schumacher and Lisa Asiaf Schlatz of Ortiz’s Health Care Fraud Unit.