OIG Issues Investigative Advisory on Medicaid Fraud and Patient Harm Involving Personal Care Service

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The following article is about the OIG's recent investigative Advisory on
Medicaid Fraud and Patient Harm Involving Personal Care Services. Feel free
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Elizabeth E. Hogue, Esq.

Office: (877) 871-4062

Fax: (877) 871-9739

Twitter: @HogueHomecare


OIG Issues Investigative Advisory on Medicaid Fraud and Patient Harm
Involving Personal Care Services

On October 3, 2016, the Office of Inspector General (OIG) of the U.S.
Department of Health and Human Services issued an Investigative Advisory on
Medicaid Fraud and Patient Harm Involving Personal Care Services (PCS). The
OIG states in this Advisory that it has found "significant and persistent
compliance, payment, and fraud vulnerabilities" in the provision of PCS or
non-medical services. According to the OIG, these problems are increasingly
important in view of the rapid growth of Medicaid Programs and the number of
individuals receiving care in their communities, as opposed to institutional

Cases investigated by the OIG show that fraud in PCS programs takes many
forms. Common examples involve payments for PCS services that were
unnecessary or never actually provided. Another common problem involves the
use of aggressive tactics when recruiting Medicaid beneficiaries to
participate in PCS fraud. Fraud in PCS programs may be difficult to
identify through review of documentation of services provided only, since
fraud often involves attendants and providers who submitted false
documentation of their activities.

Many enforcement actions now occur when individuals who know people are
engaging in fraud report such actions. According to the OIG, if the
availability and quality of data about PCS services was improved, enforcers
would be able to analyze data to identify and follow up on questionable
billing patterns. These billing patterns include:

- Claims for impossibly or improbably large volumes of services

- Claims for services that conflict with one another, i.e.,
attendants who claim to provide many hours of services to multiple
beneficiaries on the same dates

- Claims for services that could not have been performed as claimed
because of geographical distances between patients allegedly served by the
same attendants on the same days

In addition to financial losses related to fraud in PCS programs, the OIG
also found incidents of significant harm to patients. PCS fraud may involve
abuse or neglect of beneficiaries by PCS attendants resulting in death,
hospitalization or other harm to patients. PCS recipients may be unable to
report the abuse and/or neglect due to limited communication skills or
because they are dependent on attendants.

The OIG recommends the following:

- Require providers of PCS services to submit claims with more
specific details, including the exact date of services and the identity of
attendants who provided the services.

- Establish minimum Federal qualifications and screening standards
for PCS workers, including background checks.

- Require state Medicaid Programs to enroll or register all PCS
attendants and assign them unique numbers.

Private duty agencies and Medicare certified home health agencies that
provide PCS services should be prepared for a number of new regulatory
requirements, including more specific documentation of services provided.
Providers should also be prepared for a greater number of enforcement
actions, including recoupments of millions of dollars.

C2016 Elizabeth E. Hogue, Esq. All rights reserved.

No portion of this material may be reproduced in any form without the
advance written permission of the author.
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