The federal government is ramping up its efforts to nab perpetrators of Medicaid personal care services (PCS) fraud. A similar trend has been noted in Medicare home health care.
Fraud indictments of PCS providers or attendants rose 56% between 2012 and 2015, while convictions increased 33% during that time, according to a new Office of Inspector General (OIG) report.
Medicaid’s PCS benefit usually covers recipients who need help with activities of daily living (ADLs). Services might include bathing, dressing, light housework, meal prep and transportation, and are typically provided in a home or community-based setting. They may also be provided in an assisted living community or other group setting.
Overall, fraud cases involving PCS providers or attendants made up 12% of total investigations in 2015. Between 2012 and 2015, 38% of indictments and 34% of convictions involved such cases, according to the report.
One common fraud scenario, referred to as a “conflict case,” involves an attendant who claims they were providing PCS to a beneficiary while they were actually working elsewhere, OIG noted in the report.
The uptick in PCS fraud enforcement mirrors similar trends in home health care. Over the summer, the U.S. Dept. of Justice announced the largest-ever health care fraud bust, which involved schemes across several health care settings—including home health—and resulted in approximately $1.3 billion in false billings.
To help strengthen oversight of PCS, OIG made the following recommendations for the Centers for Medicare & Medicaid Services (CMS):
—Require states to enroll or register PCS attendants as Medicaid providers or assign each attendant a unique identifier.
—Institute qualification requirements and screening requirements for PCS providers.
—Require that PCS claims include the specific dates when services were performed and the identities of the PCS providers.
—Issue guidance for beneficiary assessments, plans of care and supervision of attendants.
—Consider whether additional controls are needed to ensure that PCS are allowed under program rules and are provided.
Additionally, investigators are constrained by their ineligibility to receive federal funding to enforce complaints of beneficiary abuse or neglect in non-facility settings, such as beneficiaries’ homes, OIG said. Expanding funding to include those settings would further help protect beneficiaries from abuse and neglect.
Written by Tim Regan