OIG Alleges Maryland Submitted $10.9 Million in Non-Compliant Claims for Personal Care Services
May 1, 2013 08:21 AM
In April, the Office of the Inspector General of the Department of Health and Human Services (OIG HHS) released audit findings claiming that Maryland submitted non-compliant claims for personal care services under its home and community-based services (HCBS) waiver. Based on a sample size of one hundred claims, OIG HHS estimated that from July 1, 2008 through June 30, 2010, Maryland improperly claimed $10,864,195 out of a total amount of $67,248,404 in claims to the federal government.
Of the 100 claims in the sample size, OIG HHS found that 20 claims had errors. In total, there were 24 errors in the sample size, as some claims had multiple errors. Of the 24 errors, fifteen (15) had an unqualified personal care aid, four (4) had an unapproved or missing plan of care, four (4) had unauthorized services, and one (1) had undocumented services. Out of the 15 that had an unqualified personal care aid, eleven (11) did not have a CPR certification, ten (10) did not have a first aid certification, four (4) did not have a criminal background check, and in one (1) the aid performed nursing functions by administering medications but lacked medicine aid certification. OIG HHS also concluded that Maryland lacked sufficient ability to monitor local agencies and to submit solely allowable claims to the federal government.
This OIG HHS report follows two other reports which provided audit findings of personal care services claims from personal care service providers.
January Report of Immaculate Heart of Mary-PCS in Louisiana: $820,000 in Improper Claims
In January, OIG HHS released audit findings claiming that Immaculate Heart of Mary-PCS (Immaculate), a personal care services provider in Louisiana, improperly claimed at least $820,096 out of a total $5,971,657 in claims to the federal government from October 1, 2006 through March 31, 2009.
Of the 100 claims in the sample size, OIG HHS found that 72 claims had errors, with some claims having multiple errors. Of those 72 claims, 46 claims were provided by employees who failed to complete training requirements during the State’s required timeframe. However, since these employees obtained the required training by the time services were rendered, OIG HHS did not include these 46 claims in its overpayments estimate. Services were either partially or fully unallowable due to being provided by employees who: failed to meet the State’s training requirements by the dates of service (17 claims), or failed to meet minimum education and experience requirements (8 claims). Four (4) claims were erroneous due to insufficient documentation to support the number of units claimed.
OIG HHS found three reasons for the improper claims: “1) Immaculate did not follow all of the State agency’s employee qualification requirements, 2) Immaculate did not ensure that units claimed were properly supported, and 3) the State agency did not effectively monitor its personal care services providers for compliance with the State agency’s requirements.”
March Report of The Whole Person, Incorporated in Missouri: $140,000 in Improper Claims
In March, OIG HHS released audit findings claiming that The Whole Person, Incorporated (Whole Person), a personal care services provider in Missouri that provides only consumer-directed services, improperly claimed $143,397 out of a total $4.9 million in claims to the federal government from October 1, 2008 through June 30, 2009.
Of the 100 claims in the sample size, OIG found that 9 had errors, with some claims having more than one error. OIG HHS alleged that Whole Person: did not perform an assessment or reassessment within required timeframes for six (6) line items, had a missing or unapproved plan of care for six (6) line items, and could not prove proper training of the consumer/beneficiary for one (1) line item.
OIG HHS attributed the errors to Missouri’s Department of Social Services and Department of Health and Senior Services, and Whole Person not sufficiently monitoring the personal care services program to ensure compliance with Federal and State regulations.
Home health providers should be aware that despite increased enforcement efforts, personal care service providers continue to face allegations of improper Medicaid billing, which cover a wide range of root causes including: unqualified personal care aides, unapproved or missing plans of care, unauthorized services, and undocumented services. Stakeholders should be aware of OIG HHS’ increased auditing of personal care services, and providers should redouble their efforts in compliance. Home health providers are encouraged to keep abreast of program integrity initiatives in their states, as well as nationally, and to contact NAHC with any questions or concerns.
For the full OIG HHS reports, click here, here, and here.