Significant and persistent compliance, payment and fraud vulnerabilities exist within the Medicaid program that covers home care for elderly and disabled people, according to a recent report from HHS' Office of Inspector General.
In the report, the OIG highlighted some of the most significant program vulnerabilities related to personal care services the agency continues to see during federal investigations.
The OIG said since 2012, it has opened more than 200 investigations involving fraud, patient harm and neglect in the PCS program nationwide. According to the OIG, common PCS fraud schemes involve payments for PCS that were unnecessary or not provided. Sometimes, PCS investigations detected fraud schemes organized by caregiving agencies, involving numerous attendants and beneficiaries, while other investigations have targeted individual attendants and the beneficiaries these attendants claim to serve.
"From OIG's experience, PCS providers, including agencies and individual attendants, have commonly used aggressive tactics when recruiting Medicaid beneficiaries to participate in PCS fraud schemes. Likewise, OIG has observed Medicaid beneficiaries voluntarily participating in such schemes," the OIG wrote.
The OIG report cites numerous examples. For instance, a PCS attendant in Illinois, whose nursing license had been suspended for allegedly diverting controlled substances from her employer, signed up as a caretaker and submitted claims seeking more than $34,000 for services she didn't provide.
Aside from the financial loss associated with PCS fraud, federal investigations have also shown concerning incidents of patient harm, the OIG said. Some of the OIG's cases, the agency said, have involved the abuse or neglect of Medicaid beneficiaries by PCS attendants that have resulted in deaths, hospitalizations and other degrees of patient harm.
The OIG recommended that CMS more fully and effectively help improve oversight and monitoring of PCS programs nationwide. Specific recommendations include establishing minimum federal qualifications and screening standards for PCS workers, including background checks, as well as requiring that PCS claims indicate the dates of service and the PCS attendant who provided the service.
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