Inappropriate Claims for Medicaid Personal Care Services

Eighteen percent of paid claims for Medicaid personal care services (PCS) in our universe totaling approximately $724 million were inappropriate because attendants' qualifications were undocumented.

PCS attendants provide the elderly and people with disabilities with the assistance they need to remain in their homes and communities. At its option, a State Medicaid program may provide PCS in a beneficiary's home or other community-based setting. Combined State and Federal Medicaid expenditures for PCS totaled $9.9 billion in 2006, an increase of 20 percent since 2004. States are required to institute provider safeguards to protect the health, welfare, and safety of Medicaid beneficiaries receiving PCS. Examples of safeguards include establishing attendant qualifications, such as requiring criminal background checks, and establishing minimum age, health status, education, and training requirements.

Medicaid inappropriately paid 6.5 million claims for PCS in our universe from September 1, 2006, through August 31, 2007, because attendants' qualifications were undocumented. For 43 percent of these claims, we received some documentation regarding the attendants-usually identifying information-but received no documentation to support that the attendants met any of the qualifications. For the remaining 57 percent of these claims, we received documentation to support that attendants met some, but not all, of the qualifications. Respondents failed to provide documentation of attendant background checks for 5 percent of the claims (1.7 million). Many respondents also failed to provide documentation to support that attendants met qualifications for age (1.2 million claims, or 3.5 percent) or education (451,480 claims, or 1.3 percent). Additionally, from September 1, 2006, through August 31, 2007, Medicaid inappropriately paid 2 percent of PCS claims in our universe (552,578), totaling approximately $63 million, because respondents had no record of ever providing services to the beneficiaries named in the claims data.

We recommend that CMS work with States to ensure that Medicaid claims for PCS provided by attendants with undocumented qualifications are not paid and take action regarding the inappropriately paid claims identified in our review.

CMS concurred with both recommendations. In response to the first, CMS described plans to work with States to ensure that Medicaid claims for PCS provided by attendants who do not meet States' qualifications are not paid. CMS indicated it will work through the State plan amendment and waiver review process, and other educational and communication opportunities, to address this recommendation. In response to the second recommendation, CMS stated it will review the information regarding the inappropriate claims we identified and take action based on that review.