Home Care Medicaid Fraud Developments in Florida, Maryland, and Illinois
The National Council on Medicaid Home Care – a NAHC affiliate - reports on recent developments in home care Medicaid fraud and abuse, including: 1) alleged overbilling of unauthorized services in Florida; 2) convicted fraud of a caregiver in Maryland; and 3) convicted beneficiary fraud in Illinois.
As reported by Local 10 News in Florida, on October 9, a Florida state audit found that the home care organization of the vice mayor of Broward County, Barbara Sharief, billed for unauthorized Medicaid services. The audit alleges that South Florida Pediatric Homecare (SFPH) overbilled the program $220,000, which the state is asking for back, as well as $44,000 in fines. This audit is currently being litigated.
Sharief had agreed to settle a previous audit for about $540,000, which included approximately $50,000 in fines. In this audit, the state alleged that SFPH overcharged for services lacking documentation, charging registered nursing rates when licensed practical nurses administered the services, and billed services unauthorized by physicians.
To see the news article, click here.
As reported by the Office of the Maryland Attorney General, on October 8, Carol Dunstan pled guilty to felony Medicaid Fraud for billing for personal care services not rendered. She received a suspended two-year prison sentence, and was placed on five years supervised probation. She was also ordered to pay more than $10,000 in restitution, and more than $5,000 in civil penalties, and may no longer serve as a federally-funded health care provider. She had previously been an authorized personal care provider in Maryland’s Medicaid Waiver for Older Adults Program, a home and community-based services waiver program.
Ms. Dunstan submitted timesheets for services not rendered from September 2011 through February 2012, when she was residing in Florida. A Department of Aging employee detected the fraud when the employee saw a Florida postmark on the envelope in which Ms. Dunstan mailed the fraudulent timesheets.
To see the press release, click here.
As reported by the US Attorney’s Office for the Southern District of Illinois, on September 26, Sherri Gorree pled guilty to engaging in a scheme to commit health care fraud. Sentencing will be held on January 31, 2014 in the United States District Court in East St. Louis, Illinois. Ms. Gorree faces up to 10 years in prison, up to $250,000 in fines, and as much as 3 years of supervised release.
Gorree admitted to submitting false and fraudulent claims to Illinois’ Home Services Program (IHS) for the provision of personal assistant services. She falsely billed for services for herself as a beneficiary, when the family member that was supposed to provide those services was residing out of state.
To see the press release, click here. To see previous Council articles on Medicaid home care fraud in Illinois, and on Illinois’ Home Services program, click here and 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. Further, 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 despite increased enforcement efforts, individual caregivers 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.