Home health clinical director convicted for participating in $27 million scheme; After threatening to murder a witness, a suspended behavioral health owner pleads guilty to fraud

News From Around the Web

> The clinical director of a home nursing agency in Boston was convicted of participating in a home health fraud scheme totaling more $27 million, $20 million of which Nedicare paid out. Janice Troisi, who served as clinical director of At Home VNA in Waltham, Massachusetts, joined co-conspirator Michael Galatis in 2009, training nurses to recruit Medicare beneficiaries in senior housing developments, and then manipulated assessment forms to make it look like they qualified for home health services. Galatis was previously sentenced to 92 months in prison. Announcement

> Terry Speller, who owned various outpatient behavioral health clinics in North Carolina, pleaded guilty to defrauding Medicaid after threatening to kill a witness if she spoke to law enforcement. Speller was initially investigated in 2010 after submitting Medicaid claims for behavioral health services that were never rendered. After his companies were suspended from Medicaid, he continued billing under other provider numbers, which led to more than $4 million in reimbursement. Announcement

> A Miami pharmacist pleaded guilty to Medicare fraud for submitting $1.6 million in fraudulent claims for medication that was not prescribed by physicians, not medically necessary and not provided to Medicare beneficiaries. Tamara Esponda, who owned Biomax Pharmacy, often submitted claims for drugs that were never even purchased by her pharmacy and used stolen beneficiary information in order to submit fraudulent claims. Announcement

Health Payer News

> Many of the internal controls within the government's online health insurance marketplace were unable to ensure enrolled individuals were eligible for coverage, according to a new Office of Inspector General report. In particular, controls used to validate an applicant's social security number and verify annual household income were inefficient. The OIG recommended the Centers for Medicare & Medicaid Services improve inconsistencies tied to eligibility verification. Article

> House Ways and Means Health Subcommittee Chairman Rep. Kevin Brady (R-Texas), who introduced a bill earlier this year to remove Social Security numbers from Medicare ID cards in an effort to prevent fraud, plans to draft a Medicare "premium-support" bill next year. Brady plans to save Medicare by introducing pay-for-performance reimbursement for post-acute care, and creating an out-of-pocket cap for hospital and physician coverage. Article

And finally… We didn't start the fire!! (It was the dog and a dozen cupcakes). Article

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