Home Care Medicaid Fraud Developments in Louisiana, Massachusetts, and Illinois
September 6, 2013 02:20 PM
The National Council on Medicaid Home Care, a NAHC affiliate, recently reported on developments in home care Medicaid fraud, including:
An alleged fraud by family caregivers in Louisiana;
A conviction of a caregiver in Massachusetts; and
An update on alleged caregiver fraud, beneficiary fraud, and reform efforts in Illinois.
Below are updates on these three issues in particular.
On August 28, the Louisiana Attorney General charged three individuals for billing Medicaid for services not rendered. The three defendants, members of the same family, face a total of 24 felony charges, including: criminal conspiracy to commit Medicaid fraud and filing false public records, filing false records, Medicaid fraud, racketeering, and theft by fraud, forgery and money laundering in connection with a scheme to bill Louisiana’s Medicaid program for services not actually rendered.
The family members allegedly billed Medicaid $400,000 in services not rendered on behalf of their disabled relative.
The defendants also allegedly committed cruelty to the informed by the intentional and criminally negligent mistreatment of their relative. The trio is alleged to have left their relative unattended in the evening and exposed him to injuries by two Capuchin monkeys. The relative is an adult paraplegic who is bed ridden and suffers from cerebral palsy.
These charges arise from a larger criminal enterprise where direct service workers billed Medicaid for caring for immediate family members 24 hours a day, seven days per week. The period of the false billing occurred from January 1, 2009 through August 21, 2013.
To see the full story, click here.
On August 26, Daniel Keegan was placed on probation with a suspended jail sentence for Medicaid fraud. He was also ordered to pay restitution for an amount to be determined. From November 2007 through October 2011, the defendant and his sister submitted time sheets for the care of his son. According to the prosecutor, Mr. Keegan did not provide the services as he had conflicting appointments, was travelling, or was otherwise not living in Massachusetts at the time.
After Mr. Keegan received the Medicaid payments, he would transfer them to his sister via checks, according to Assistant Attorney General Casey Groff. Groff stated that over $93,000 of the $103,000 that Mr. Keegan received was for services not rendered by Mr. Keegan.
Mr. Keegan pled guilty to larceny of more than $250 and medical assistance fraud in Worcester Superior Court. The judge sentenced him to two years imprisonment, but suspended the sentence for five years with probation.
Mr. Keegan is due in court on September 30 for a pre-trial conference and restitution hearing, and on November 2 for his trial. Once the total amount of restitution is determined, Mr. Keegan will be required to pay at least $65 a month. Following his 5 years probation, Mr. Keegan will then have to pay any outstanding restitution.
To see the full story in Massachusetts, click here. To see previous articles on arraignments and charges of personal care attendants in Massachusetts, click here and here.
With July 11 indictments, federal prosecutors brought the number of people charged with defrauding Illinois’ Home Services program (IHS) to 29, including 18 personal assistants and 11 beneficiaries. An earlier series of similar indictments were brought in 2012. The Illinois program is a consumer-directed Medicaid waiver program that enables disabled individuals under 60 years of age to stay in their homes by providing them with assistance in performing activities of daily living. Generally, the indictments charge the individuals with fraudulently billing Medicaid for services not rendered by the caregivers ad not needed by some of the recipients.
In addition to the enforcement actions, the US Attorney’s office and the members of the Illinois legislature have indicated that changes in state laws are under consideration to prevent or reduce the risk of future fraudulent conduct in the program. Stephen Wigginton, U.S. Attorney for the Southern Illinois District, and State Rep. Greg Harris (D-Chicago), Chair of the House Human Services Appropriations Committee, had a preliminary conversation about potential legislative changes to IHS to prevent further fraud. Harris commented that hearings will likely occur, but did not set specific dates for these as doing so would interfere with ongoing investigations. State Rep. David McSweeney (R-Lake Barrington) also came out in favor of these hearings, specifically calling for “a review of the entire program and training components.”
Illinois, unlike most states, does not require mandatory training for personal care assistants. Illinois lacks supervision mechanisms, also unlike most states. Current training is voluntary and has been enacted as a result of collective bargaining with the Service Employees International Union (SEIU). Only approximately 8% of personal care assistants have gone through this voluntary training program. SEIU is reportedly supporting strengthening the program.
To see the full story in Illinois, click here.
To see a previous Council article on earlier indictments in Illinois -and on Illinois’ Home Services program - click here.
To see earlier articles from the Council on alleged and established home care Medicaid fraud in Missouri and Rhode Island, clickhere, Alaska and Louisiana, click here, Kentucky and Virginia, click here, and New Jersey, Illinois, Oregon, and Alaska, click here.
As Medicaid home care spending increases, anti-fraud efforts have focused more resources in a variety of “risk areas.” Recent prosecutions have highlighted serious program integrity weaknesses in both consumer-directed and agency model personal care assistance programs. These prosecutions include many cases of billing for services never rendered and include allegations of beneficiary complicity as well. Often family members are involved.
It can be anticipated that investigations and prosecutions will continue for some time to come as states share information and strategies. Home care companies doing business with Medicaid would be well served if they redouble their internal program integrity efforts. Home care companies should utilize service attendance and documentation systems that provide reliable ways to validate any self-submitted information.
Agencies should engage in at least spot checks with recipients to ensure actual delivery of care and continued eligibility for services. In many circumstances, Medicaid will attempt to recover any fraudulent payments from the agency even if the agency is not implicated in the fraud. In addition, the fraud of an employee can create a risk that the employer is also charged with fraud. Home care companies should anticipate future regulatory and legislative action to stem the growing instances of home care fraud, as is seemingly on the horizon in Illinois. This is a typical reaction to health care fraud with regulators believe that all problems can be solved through another layer of rules. To the extent that there is a need for reforms, it is important to craft sound legislation that protects patients while putting the fewest restrictions on honest caregivers.
Home care companies should be aware that with the increased enforcement efforts, individual caregivers will continue to face allegations of Medicaid fraud, primarily focused on billing for services not rendered. These trends have contributed to a movement to require background checks for caregivers, and stakeholders should actively engage in that process through the forums or state advocacy.
It appears that the concerns with billing for services never rendered are especially acute in consumer-directed care programs. While these types of home care delivery models provide an important level of control to the client, they also run a higher risk of fraud, particularly where the caregivers are from the client’s family. These risks may provide home care agencies with an opportunity to supply some program integrity oversight along with caregiver training and supervision. At the same time, agencies should guard against Medicaid programs promulgating new regulatory measures that affect agency-model and consumer directed care equally.
Home care companies are encouraged to keep abreast of program integrity initiatives in their states, and to contact the Council with any questions or concerns.