OIG Report Finds Persistent Medicaid Abuse in Personal Care Services
October 5, 2016 10:53 AM
Federal investigators in the Department of Health and Human Services’ Office of Inspector General (OIG) are calling for reform after finding more than $600 million of questionable Medicaid billing from November 2012 to August 2016.
A new OIG report revealing the alleged abuse is sharply critical of Medicaid for not sufficiently cracking down on what investigators characterize as persistent fraud and abuse in Medicaid-funded personal care services. Better regulation and oversight is needed to prevent fraud and patient neglect, according to the OIG. The report is a compilation of findings and insights gained through several Medicaid audits and studies performed by the OIG in past years. Essentially, it is a trend report that was triggered by what the OIG perceives as a pattern of fraud and abuse in Medicaid personal care services.
Personal care services (PCS) are nonmedical assistance to the elderly, disabled and people with chronic or temporary conditions, so they can remain in their homes. PCS has expanded considerably since Olmstead v. L.C., a 1999 United States Supreme Court case holding that unjustified institutionalization of people with disabilities violates the Americans with Disabilities Act.
PCS fraud takes many forms, the OIG found. The PCS fraud that has been uncovered predominately involves “consumer-directed care” model services where the personal care aide is directly employed by the Medicaid recipient. However, the OIG notes that the fraud schemes also include agency-model programs where the aide is employed by a home care company.
The most common schemes involve payment for services that were unnecessary or not actually provided. However, fraud is usually difficult to find simply by reviewing documents. Most fraud cases involving PCS are discovered only through referrals from people who know that others are committing the fraud. However, an improvement in the quality and availability of PCS data would allow states, CMS, OIG and others to identify questionable billing practices – such as improbably large volumes of services, services that actually conflict with each other and services that could not have been rendered because the attendant was literally not in the same place as the Medicaid beneficiary.
The OIG report cited the example of a PCS attendant in Illinois who submitted claims for $34,000 for services never rendered to the beneficiary. The caregiver, who was barred from all federal health programs after she lost her nursing license for diverting controlled substances from her employer, claimed to have provided PCS to the beneficiary while the nurse was actually on vacation in the Caribbean.
Other, more serious examples of fraud, include considerable harm to the patient, such as a Pennsylvania beneficiary who died of exposure to cold because of a PCS attendant who lost the patient while shopping in Philadelphia and waited an hour before alerting authorities.
A big part of the problem, according to OIG, is a lack of consistent national standards for personal care workers. To remedy that, the OIG recommends “minimum federal qualifications and screening standards” for personal care workers, including background checks. Furthermore, the OIG recommends that CMS:
require states to enroll or register all PCS attendants and assign them unique numbers;
require that PCS claims identify the dates of service and the PCS attendant who provided the service;
consider whether additional controls are required to ensure that PCS are allowed under program rules and are provided.
The OIG report urges CMS to take regulatory action to establish safeguard that will prevent fraudulent or abusive providers from enrolling or remaining as PCS attendants.
Disturbingly, the OIG points out it issued a major report detailing many of the same abuses in 2012, and no major changes have happened as of yet.
NAHC has taken an aggressive role in combatting the risks of fraud in Medicaid PCS programs. For example, NAHC has supported appropriately targeted use of electronic visit verification systems that provide real-time tracking on the actual delivery of care to Medicaid clients. In addition, NAHC has strongly supported the development of competency standards for personal care aides providing Medicaid services along with credentialing of Medicaid home care agencies. Medicaid spending on home care has grown to over $70 billion annually, surpassing Medicaid nursing home spending for the first time in 2015. Still, the “rebalancing” of long term care spending in favor of home care has triggered concerns such as those highlighted in the OIG Investigative Advisory. NAHC will continue to work to reshape Medicaid into a community-based care program while strengthening program integrity to ensure that limited Medicaid dollars are not misspent.