By Richard Kusserow, former HHS Inspector General and CEO of Compliance Resource Center. Reprinted from his Wolters Kluwer‘s Kusserow on Compliance Blog
The HHS OIG issued an “Investigative Advisory on Medicaid Fraud and Patient Harm Involving Personal Care Services” (PCS), a 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. It is typically provided by an attendant who works for personal care agencies enrolled in the Medicaid program. PCS is an optional Medicaid benefit that States may choose to provide under State plan options and/or through Medicaid waiver and demonstration authorities approved by CMS and it is their responsibility to develop qualifications or requirements for attendants to ensure quality of care. The OIG has issued a number of reports concerning high levels of improper payments, questionable care quality, and high amounts of fraud summarized in a Portfolio of 2012. The current report provides additional data concerning the problem and included results of a survey of State Medicaid Fraud Control Units (MFCUs) about fraud trends in the PCS program. Since that report, the OIG has opened more than 200 investigations involving fraud and patient harm and neglect in the PCS program across the country.
The OIG cited a number of examples of different schemes and the negative consequences, including billing for PCS either not necessary or not actually provided; recruiting Medicaid beneficiaries to participate in fraud schemes; and noting instances where patients were harmed, as result of abuse or neglect, resulting in some cases in hospitalizations and even death. The OIG reported discussing potential administrative actions with the CMS, including:
- Issuing informational bulletins to states on how to improve internal controls for PCS.
- Establishing minimum Federal qualifications and screening standards for PCS workers, including background checks.
- Requiring 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.
- Considering whether additional controls are needed to ensure that PCS are allowed under program rules and are provided.