Medicaid Personal Care Fraud Escalates

Many affordable housing residents depend on Medicaid funded more Personal care services (PCS) as a lifeline to help them remain in the community. 

It is unfortunate that we are seeing a trend of persistent fraud and abuse in Medicaid-funded personal care services.  The Office of Inspector General (OIG) found more than $600 million of questionable Medicaid billing from November 2012 to August 2016.

The new OIG investigative advisory concludes that Medicaid agencies are not sufficiently regulating and overseeing Personal care services (PCS) providers. Also, the OIG states there is a lack of consistent national standards for personal care workers. The OIG recommends “minimum federal qualifications and screening standards” for personal care workers, including background checks.

A major finding in the investigative advisory is that the PCS fraud predominately involves “consumer-directed care” model services where the personal care aide is directly employed by the Medicaid recipient. We have seen fraud involving 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. There is currently legislation in the Congress that would require states to mandate electronic visit verification systems that provide real-time tracking on the actual delivery of care to Medicaid clients. 

Also, the OIG recommends that CMS:

• Improve the quality and availability of PCS data in order to 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.
• 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. 
• Take regulatory action to establish safeguard that will prevent fraudulent or abusive providers from enrolling or remaining as PCS attendants.

States have limited Medicaid funds, and the Congress has been discussing further limits on federal Medicaid dollars through block grants and per-capita cap funding limitations. No matter if your organization provides Medicaid personal care services or not, Medicaid fraud results in reductions in Medicaid funding for adult day services, home care, PACE and other important services for frail elders and persons with disabilities.