As at-home care has increasingly become a more popular model for health care, a significant portion of fraud convictions over the last 10 years have involved personal care services attendants.
Between 2014 and 2023, personal care services accounted for at least 34% of fraud convictions in some years and as much as 48% in other years.
That’s according to a new report from OIG that detailed the findings from Medicaid Fraud Control Units (MFCUs). MFCUs are mandated by the Social Security Act to investigate and prosecute Medicaid provider fraud and patient abuse or neglect.
MFCUs are in all 50 states and are jointly funded by the federal and state governments.
In fiscal year 2023, these units reported 1,143 convictions, which, while higher than in FY 2020, remained lower than pre-pandemic levels. The number of convictions had steadily declined during FY 2020 — aligning with the onset of the COVID-19 pandemic — which indicates a “sustained impact on enforcement activities,” OIG wrote in its report.
However, there seems to be ongoing issues related to fraud in personal care.
While personal care attendants made up a significant amount of convictions, they also represented a higher percentage than all other provider types.
In FY 2023, OIG found personal care services accounted for 279 convictions compared to 66 for nurses, 43 for home health agencies, 33 for ophthalmologists and 36 for mental health facilities.
The OIG report cited 43 criminal convictions from home health agencies and 26 civil settlements in 2023.
Of the dozens of provider types listed in the report, home health fraud convictions totaled the highest in recoveries at $34.6 million. Other notable provider types near the top of the list were surgeons ($26.8 million), personal care service agencies ($26.4 million) and suppliers of durable medical equipment ($23.6 million).
The 1,143 criminal convictions totaled $272 million in recoveries and the 436 civil settlements totaled about $962 million.
This week, Family First Home Health Care, a personal care agency based in North Carolina, reached a settlement of $600,000 to settle accusations of submitting fraudulent Medicaid claims from 2015 to 2020, which violated both federal and North Carolina False Claims Acts.
The government alleged that Family First and its owner Marion James billed Medicaid for in-home personal care services that were never performed on days when patients were hospitalized.
As for the federal government’s crackdown of these cases, the crime units seem to be paying off.
“The amount of civil recoveries reached a 4-year high in 2023 and the combined criminal and civil recoveries were $1.2 billion, resulting in an ROI of $3.35 for every $1 spent,” the OIG reported.
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