OIG Releases Investigative Advisory on Medicaid Fraud & Patient Harm Involving Personal Care Services

carer and elderly ladyPersonal care services came under the increasingly watchful eye of the Office of Inspector General this week, when the department released a scathing memo calling into question Medicaid reimbursements for non-medical services provided to assist with activities of daily living, such as bathing, dressing, light housework, medication management, meal preparation, and transportation. Although these services save millions of dollars by keeping seniors and the disabled out of nursing homes, the OIG has identified many cases of fraud and abuse across the country, and has designated it as an area that “requires priority, attention, and action.”

On Monday Larry Goldberg, principal deputy inspector general for the Department of Health and Human Services Office of Inspector General (OIG), released a memo recently highlighting the OIG investigations into the Personal Care Services Program.  In it, he provided insights into two areas of growing concern for the federal government: Medicaid’s personal care services (PCS) program and Medicare’s improper payments to skilled nursing facilities (SNFs).

In explaining the issues surrounding the PCS program, Goldberg introduced the new OIG Portfolio and described why Medicaid PCS was the first area to be included in it.

As described in the Portfolio, our audit and evaluation work revealed a pattern of improper PCS payments linked to lack of compliance with State policies and requirements and found that existing controls designed to prevent improper payments are ineffective. Furthermore, PCS fraud — including many cases when the care attendants and the beneficiaries act as co-conspirators to scam the Medicaid system — is on the rise, representing more cases investigated by State Medicaid Fraud Control Units than any other type of Medicaid fraud.- Goldberg

OIG: Additional Oversight is Needed for Medicaid PCS

Since 2006, the OIG has conducted numerous fraud investigations and issued 23 reports on the topic of PCS. Goldberg reported that in 2011, the Medicaid program spent almost $13 billion for these services, which represented a 35 percent increase in payments since 2005. According to Goldberg, one state had payment error rates hit 40% and submission of fraudulent claims increased. He calls these findings a “top concern for OIG,” and explains the problem as follows.
The OIG found that Medicaid paid claims for care attendants who didn’t meet the basic qualification standards and also identified documentation indicating that care was given in nursing home or institution instead of in the home, which is the purpose of the benefit. OIG recommended that the Centers for Medicare & Medicaid Services (CMS) require that:
UPCOMING WEBINAR: Protect Yourself from Negative Accusations & Investigations
Based on this action by the OIG as related to Trends, Vulnerabilities, and Recommendations for Improvement in the PCS program, we want to invite your aides and your nurse aide supervisors to participate in our educational webinar on this topic, scheduled for October 18 from 3-4pm. Many actions by the OIG will be discussed as well as recommendations the aides can take to ultimately protect themselves and their agencies. The webinar recording is available for 30 days so that all aides will have an opportunity to learn after the live presentation. It’s all about protecting your good name!
  1. All individuals who provide these services meet minimum qualification standards, register with the state, and obtain their own individual identification numbers
  2. Submitted claims include not only the date when services were performed but also the type of services provided
“At bottom, we need to be sure Medicaid is paying for and patients are receiving the most appropriate care possible,” said Goldberg. To improve billing problems, CMS should specify how:

  • Claims should be documented
  • Patient needs should be assessed
  • Patient plans of care should be developed
  • Attendance should be supervised.
In response, CMS generally expressed that more needs to be done to address these concerns, but only explicitly agreed with the recommendation to provide States with more data for identifying over payments. OIG maintains that the recommended actions are necessary to protect the integrity of the Medicaid PCS program and ensure that vulnerable populations continue to have access to this vital benefit.

Investigative Advisory

In this investigative advisory, OIG identifies concerns about fraud and patient harm that build upon those outlined in a Portfolio report issued in November 2012, Medicaid Personal Care Services: Trends, Vulnerabilities, and Recommendations for Improvement.
Since the Portfolio process was issued in 2012, OIG has opened more than 200 Federal criminal investigations involving fraud and patient harm and neglect in the PCS program across the country and has included PCS cases as part of national health care fraud takedowns in 2015 and 2016. OIG investigations have revealed a variety of billing fraud scenarios, some of which are limited to individual PCS workers, while others indicate organized schemes involving dozens of suspects. OIG investigations have also shown that abuse and neglect by PCS attendants has resulted in deaths, hospitalizations, and less severe degrees of patient harm. Stronger controls are needed to screen and monitor PCS attendants and the program.

OIG Recommendations

CMS also should issue guidance to states about prepayment controls because, as he noted, “It’s much more difficult to recover money after the claims have been paid.”

In addition to implementing the recommendations found in previous reports that have yet to be adopted, the OIG personal care services portfolio proposes several new recommendations for programmatic improvement.

  • CMS should more effectively leverage its authorities to oversee the Medicaid PCS program by
    • making qualification standards for PCS care attendants more consistent,
    • requiring care attendants to be enrolled or registered with the State
    • requiring dates, times, and attendants’ identities to be listed on PCS claims to Medicaid, and
    • expanding Federal requirements and guidance to reduce variation of requirements for claims documentation, beneficiary assessments, plans of care, and supervision of attendants across States.
    • OIG also recommends that CMS issue guidance to States regarding adequate prepayment controls and provide States with the data they need to identify over payments occurring when beneficiaries are receiving institutionalized care.
    • CMS should consider whether additional program controls are needed.

NAHC: OIG Report Finds Persistent Medicaid Abuse in Personal Care Services


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