On September 11, 2015, the Office of Inspector General (OIG), Director of Medicaid Audits, John Hagg, testified before the House Committee on Energy and Commerce regarding areas in need of corrective action within the Centers for Medicaid & Medicare Services’ (CMS) administration of state Medicaid programs. Mr. Hagg’s testimony focused on three specific areas – (1) the issue of terminated providers continuing to participate in and bill Medicaid; (2) the prevention of fraud in reimbursement for non-medical personal care services; and (3) the need for Medicaid Fraud Control Units (MFCUs) in the five U.S. territories and the state of North Dakota. This article focuses on the second part of Mr. Hagg’s testimony – his recommendations and proposed corrective actions to prevent fraud in personal care services.

The provision of personal care services such as bathing, meal preparation or light housework often can allow the elderly and those with disabilities (or chronic or temporary conditions) to remain in their own homes rather than being placed in a nursing facility or other institutionalized care setting. In an effort help eligible Medicaid beneficiaries who wish to remain in their homes, State Medicaid programs provide reimbursement for the provision of personal care services by care attendants. Over the last few years, OIG and the Medicaid Audits division have conducted investigations and issued numerous reports regarding fraud and abuse in the provision of personal care services. According to Mr. Hagg, the investigations and reports demonstrate that significant problems with fraud and abuse continue to increase. Specifically, reimbursement for these services is routinely found improper because the services were not provided in compliance with State requirements, were unsupported by documentation, were provided while the beneficiary was not in his or her home, or were provided by unqualified attendants. Additionally, there are persistent issues with the safeguards designed to prevent improper payments and ensure medical necessity, patient safety and quality.

In an effort to help CMS and State Medicaid programs address the identified issues and deficiencies, OIG has made the following recommendations:

• Make qualification standards for care attendant/providers more consistent among States;
• Require care attendant/providers to be enrolled or registered with the State;
• Require care attendant/providers identities, dates of service, and times of service to be listed on Medicaid claims;
• Expand Federal requirements and guidance to reduce variation of requirements for claims documentation, beneficiary assessments, plans of care, and supervision of attendants across States;
• Issue guidance to States regarding prepayment controls;
• Assess whether additional controls are necessary to ensure services are allowed and provided;
• Provide States with data to assist in identification of overpayment or payments when beneficiaries are not in their home or ineligibles.

In response to the recommendation, CMS agreed that more needs to be done and intends to take a number of steps to address the recommendations.

Accordingly, providers of personal care services reimbursed by Medicaid should anticipate changes regarding the recommended areas as well as increased scrutiny of their claims as CMS seeks to ramp up efforts with personal care programs.

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OIG’s Director of Medicaid Audits Testifies About Recommendation to Prevent Fraud in Personal Care Services