On December 13, 2016, the Centers for Medicare & Medicaid Services (CMS) released an information bulletin to the states and other stakeholders regarding personal care services (PCS) program integrity vulnerabilities, and safeguards state Medicaid agencies can implement to strengthen program integrity in personal care services.
Program Integrity Vulnerabilities
Findings from the Office of the Investigator General
- Services not provided in compliance with state requirements
- Services not supported by documentation
- Services provided during periods in which the beneficiaries were in Medicaid reimbursed institutional stays
- Payments for retaining the attendants during the institutional stay had not been authorized
- Services provided by PCS attendants who did not meet state qualification requirements
- Billing for services not rendered
- Billing for services furnished to ineligible beneficiaries
- Billing for services furnished by unauthorized caregivers
- Instances of abuse and neglect of beneficiaries by PCS attendants, resulting in beneficiary harm
Recommended Safeguards to strengthen program integrity in personal care services
States establish adequate post payment review processes for PCS, including implementing post-payment review processes specific to self-directed PCS.
Agencies should refer to the CMS guidance to avoid improper billing and the sanctions that apply to fraud, including civil monetary penalties, criminal fines, imprisonment, and exclusion from participation in Medicaid, Medicare, and other Federal health care programs.
Qualifications for PCS attendants can include possession of a valid driver’s license, a minimum age threshold, and the receipt of any training
Some states require basic competency-based training such as first aid and CPR certification, etc.
States should consider establishing a centralized data bank for PCS that would be accessible to PCS agencies as well as to beneficiaries. The data bank could include: a registry of qualified PCS attendants, registration of the PCS agency with the Medicaid agency, excluded PCS agency data.
Federal regulations require that all providers furnishing services to Medicaid beneficiaries on a fee-for-service basis be screened and enrolled in the Medicaid program. (CMS will require compliance with this requirement by states and managed care plans with managed care contracts beginning on or after July 1, 2018).
PCS providers must be able to document the provision of services for which they have submitted a claim for payment. CMS notes that states could require PCS attendants to document the provision of services with some kind of verification mechanism. Section 11600 of the State Medicaid Manual indicates that claims for any Medicaid service must be reviewed to ensure the following:
- It contains all the required information (which includes the date(s) of service, who provided the service
- It contains where the service was provided, length of time required for the service, if relevant, and third party billing information)
- It contains information that is internally consistent
- It contains information on the individual who received the service and the provider who submitted the claim were certified as eligible to participate in the program on the date(s) of service and the service provided is covered under the program
- States check if the service does not exceed frequency limitations; and any required prior authorizations or certifications were obtained
CMS recommends States and PCS providers should review the common documentation and billing errors relating to PCS and promising practices for correcting them.