United States v. Troisi
2017 WL 727554
1st Cir.
2017

Background

  • Janice Troisi became Clinical Director of At Home VNA (AHVNA) on January 1, 2010; AHVNA submitted Medicare claims from 2006–2012, billed $27.6 million, and received $19.9 million.
  • Indicted (2013) on conspiracy (18 U.S.C. § 1349) and multiple substantive healthcare-fraud counts (18 U.S.C. § 1347); proceeded to a bench trial in 2015 after a prior jury trial mistrial due to her illness.
  • Government’s theory: AHVNA recruited ineligible Medicare beneficiaries, falsified OASIS assessment forms and Form 485 certifications, and billed Medicare for skilled in-home nursing services not needed or not provided. Dr. Wilking signed forms without reviewing patients.
  • Troisi supervised inexperienced nurses, reviewed and edited OASIS forms at weekly meetings, personally completed Form 485s for physician signature, and directed nurses to change entries (e.g., never record “zero” independence), overriding nurses’ discomfort.
  • Troisi argued at trial and on appeal that, although she performed the challenged acts, the government failed to prove she had the requisite mens rea (willful knowledge and specific intent to defraud).
  • The district court convicted Troisi on all counts and sentenced her to 36 months’ imprisonment; the First Circuit affirmed, holding circumstantial evidence supported a finding of knowledge and intent.

Issues

Issue Plaintiff's Argument Defendant's Argument Held
Sufficiency of evidence that Troisi acted with required mens rea for § 1347 and § 1349 Gov: circumstantial evidence (control of documentation, instructing nurses, falsifying forms, knowing regulations) shows knowing, willful intent to defraud Troisi: performed tasks but lacked criminal intent; was an "aggressive" manager ensuring care, not intending fraud Affirmed — reasonable factfinder could infer willful knowledge and specific intent from circumstantial evidence
Whether knowledge of Medicare rules and practice supports inference of intent Gov: Troisi’s familiarity with regs and claimed expertise in PPS supports knowledge that forms were false and fraudulent Troisi: regulatory familiarity does not prove intent to defraud; could reflect clinical/administrative competence Affirmed — regulatory knowledge, plus conduct, supports inference of culpable state of mind
Whether control over documentation and instructions to nurses establishes culpability Gov: Troisi’s edits, replacement pages, specific directives to nurses, and completion of Form 485s for signature were direct acts furthering scheme Troisi: managerial oversight or efforts to secure services patients needed; edits were supervisory, not fraudulent Affirmed — control and affirmative steps to alter records permit an inference of knowing participation
Use of circumstantial evidence to prove conspiracy and substantive fraud Gov: circumstantial proof permitted; consistent badges of fraud across counts Troisi: claimed insufficiency because no direct proof she intended to defraud Medicare Affirmed — case law permits conviction on circumstantial record when inferences are reasonable

Key Cases Cited

  • López-Díaz v. United States, 794 F.3d 106 (1st Cir. 2015) (standard for assessing sufficiency of evidence and inferences from circumstantial proof)
  • Flores–Rivera v. United States, 787 F.3d 1 (1st Cir. 2015) (circumstantial-evidence principles in criminal sufficiency review)
  • Spinney v. United States, 65 F.3d 231 (1st Cir. 1995) (deference to reasonable inferences from circumstantial evidence)
  • O'Donnell v. United States, 840 F.3d 15 (1st Cir. 2016) (any rational trier of fact standard for sufficiency)
  • Iwuala v. United States, 789 F.3d 1 (1st Cir. 2015) (elements of healthcare-fraud and conspiracy convictions; circumstantial proof permitted)
  • Vega v. United States, 813 F.3d 386 (1st Cir. 2016) (inference of intent from insistence on qualifying patients and allowing reimbursement for patients doctors did not see)
  • Singh v. United States, 390 F.3d 168 (2d Cir. 2004) (possession of billing guide and instructions to staff can support inference of fraudulent intent)
  • Willett v. United States, 751 F.3d 335 (5th Cir. 2014) (proximity to and control over fraudulent activities bears on culpability)
  • Njoku v. United States, 737 F.3d 55 (5th Cir. 2013) (instructions to misrepresent homebound status on OASIS support culpable state of mind)
  • Eghobor v. United States, 812 F.3d 352 (5th Cir. 2015) (sufficiency where defendant falsified OASIS and created Form 485s signed by doctor who never treated patients)
  • Hatch v. United States, 434 F.3d 1 (1st Cir. 2006) (standard for guilty verdict support)
  • LaPlante v. United States, 714 F.3d 641 (1st Cir. 2013) (willfulness and specific intent explained)
  • Allen v. United States, 670 F.3d 12 (1st Cir. 2012) (willfulness requires purpose to disobey or disregard law)
  • Gonzalez v. United States, 570 F.3d 16 (1st Cir. 2009) (willfulness and specific intent principles)
  • Lizardo v. United States, 445 F.3d 73 (1st Cir. 2006) (willfulness and mens rea discussion)
  • Bryan v. United States, 524 U.S. 184 (1998) (treatment of willfulness in criminal statutes)
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