Authorities Indict Fourteen for Personal Care Assistant Fraud in Illinois
July 3, 2014 09:10 AM
On June 5, federal and state officials announced the indictment of fourteen independent personal care assistants and Medicaid beneficiaries for home care fraud in the third wave of “Operation Home Alone” in Illinois. The first and second rounds, in May 2012 and July 2013, respectively, indicted a total of 29 people. Operation Home Alone was established to crack down on individuals defrauding Illinois’ Home Services Program.
The types of fraud involved, as well as the number of individuals charged for each, include:
Services billed while the personal care assistant or the beneficiary was in the hospital (6)
Services billed while the personal care assistant or the beneficiary was in prison (4)
Services billed while the personal care assistant or the beneficiary was working (3)
Services billed while the beneficiary was dead (1)
The fourteen individuals together face a total of twelve indictments, and a maximum 10-year prison sentence, $250,000 fine, and three year supervised release.
Illinois currently lacks both mandatory training for personal care assistants, as well as supervision mechanisms, 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 FBI’s press release, click here.
In a March 2014 press release, Stephen R. Wigginton, United States Attorney for the Southern District of Illinois, stated: “Nationwide, the biggest fraud problem in the Medicaid program has been these personal assistant programs which represent the number one fraud complaint to state Medicaid fraud units.” It appears that the concerns with billing for services never rendered are especially acute in consumer-directed care programs, as is the case in the Illinois and Massachusetts personal care programs, and Florida’s Consumer Direct Care Plus program. As Wigginton further stated:
Especially vulnerable to fraud are programs, such as the one implemented in Illinois, that allows the Medicaid recipient to control the selection and payment of personal care attendants. In most cases, the personal care assistant is a relative or family friend, who often is a ghost employee. In a typical fraud scenario, the scam payments made by the State of Illinois are split between the Medicaid recipient and the ghost employee. [Illinois press release].
While consumer-directed care programs 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 doing business with Medicaid would be well served if they redouble their internal program integrity efforts. Home care companies should use 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.
Increasing regulation and legislation is a typical reaction to health care fraud, as regulators believe that they can solve all problems 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. Stakeholders should actively engage in the process of regulatory and legislative reform through the forums or state advocacy. 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.
NAHC and its affiliate, the National Council on Medicaid Home Care, has always had a zero-tolerance policy for those who would look to divert funds from Medicare or Medicaid for their own personal gain. We have taken a very focused and aggressive approach to fraud concerns in home health care. “The fraud committed by the very few, hurts all of home care and the patients we serve. The industry must be a leader in health care compliance and program integrity. NAHC has made great progress in that regard and will continue to set the gold standard for all of health care,” stated NAHC president, Val J. Halamandaris.