An investigative advisoryissued by the HHS Office of Inspector General (OIG) summarizes fraud schemes in federal investigations involving personal care services (PCS) and offers recommendations to CMS to combat fraud and patient harm in the Medicaid PCS program. PCS provide nonmedical assistance to the elderly, people with disabilities, and individuals with chronic or temporary conditions so that they can remain in their homes and communities. The OIG’s examination of Medicaid PCS found significant compliance, payment, and fraud vulnerabilities. The OIG recommends that CMS improve oversight and monitoring of PCS programs across the country. The OIG believes that if CMS issues regulations consistent with OIG recommendations, it will be better able to prevent and detect improper payments, facilitate enforcement efforts, and reduce the risk of beneficiaries being exposed to substandard care (OIG Report, October 3, 2016).
PCS fraud schemes. Cases investigated by OIG show that PCS fraud schemes commonly involve payments for PCS that were unnecessary or not provided. From the OIG's experience, PCS providers, including agencies and individual attendants, have commonly used aggressive tactics when recruiting Medicaid beneficiaries to participate in PCS fraud schemes. The OIG also has observed some Medicaid beneficiaries voluntarily participating in such schemes.
At present, the OIG reports that most fraud cases involving PCS come to the attention of law enforcement only through referrals from individuals who know the people committing the acts. However, the OIG believes that if the availability and quality of PCS data were improved, states, CMS, and the OIG could analyze the data to identify and follow up on aberrancies and questionable billing patterns. Also, many states do not enroll, register, or identify attendants on claims submitted for payment. If claims contained more specific details, including the exact dates of service and the identity of the attendants, such irregular billings could be more easily discovered through claims analysis by state program integrity units.
Patient harm. In addition to the financial loss associated with PCS fraud, some of the OIG's investigations have involved the abuse or neglect of beneficiaries by PCS attendants that have resulted in deaths, hospitalizations, and other less severe degrees of harm. Other cases have involved attendants caring for beneficiaries while impaired, sometimes by drugs that had been prescribed to the beneficiaries in their care. Moreover, because most attendants deliver care without supervision from other providers, monitoring the delivery of care falls on the beneficiary or their family. This monitoring can be very problematic because many Medicaid beneficiaries receiving PCS may have physical or cognitive impairments that make it difficult for them to closely monitor their attendants.
Recommendations. OIG recommends that CMS prevent fraud and patient harm and neglect in Medicaid PCS by implementing the following recommendations:
- establish minimum federal qualifications and screening standards for PCS workers, including background checks;
- 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; and
- consider whether additional controls are needed to ensure that PCS are allowed under program rules and are provided.
CMS has issued a July 2016 booklet regarding preventing improper payments in Medicaid PCS.
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