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

In this investigative advisory, OIG identifies concerns about fraud and patient harm that build upon those outlined in a Portfolio report issued in November 2012, Medicaid Personal Care Services: Trends, Vulnerabilities, and Recommendations for Improvement (OIG-12-12-01). The Portfolio provided recommendations to address vulnerabilities in Medicaid PCS that OIG detected in more than two dozen previously published audits and evaluations and hundreds of completed State and Federal investigations. Since the Portfolio was issued in 2012, OIG has opened more than 200 Federal criminal investigations involving fraud and patient harm and neglect in the PCS program across the country and has included PCS cases as part of national health care fraud takedowns in 2015 and 2016. OIG investigations have revealed a variety of billing fraud scenarios, some of which are limited to individual PCS workers, while others indicate organized schemes involving dozens of suspects. OIG investigations have also shown that abuse and neglect by PCS attendants has resulted in deaths, hospitalizations, and less severe degrees of patient harm. Stronger controls are needed to screen and monitor PCS attendants and the program. OIG recommends that CMS implement the following key unimplemented recommendations from OIG's PCS Portfolio: establish minimum Federal qualifications and screening standards for PCS workers, including background checks; require 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; and consider whether additional controls are needed to ensure that PCS are allowed under program rules and are provided.

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