Documenting that personal care services for Medicaid beneficiaries were provided when they were not may result in the submission of false claims
Compliance Perspective – Fraud
Policies/Procedures: The Compliance and Ethics Officer with the Administrator will review the policies and procedures regarding Reimbursement Auditing.
Training: The Compliance and Ethics Officer will ensure that the staff are trained to determine if submitted billing for provided services matches time constraints for providing those services. Staff should always include a reasonableness approach in their review.
Audit: The Compliance and Ethics Officer will conduct an audit to determine if the billing matches the services provided.
A woman employed as a personal care aide drew the attention of the District of Columbia Department of Health Care Finance after she was identified as the second-highest paid personal care aide in 2014 and 2015. She was recently arrested on a criminal complaint that charged her with healthcare fraud and making healthcare false statements.
According to the complaint, the defendant worked from January 2014 through December 13, 2018,when she was arrested, as a personal care aide who assisted Medicaid beneficiaries with their daily activities. Those activities included helping beneficiaries bathe, dress, take medication, get in and out of bed, and with their toileting.To receive personal care services under Medicaid, a beneficiary must obtain a prescription from a physician.
Based on a review of the Medicaid billing claims data for the period between January 2014 and January 2017, the defendant caused Medicaid to issue payments totaling approximately$434,000, including payments based on fraudulent time sheets. Some of the claims submitted actually billed for more than a 24-hour period in a given day, for services allegedly provided while she was out of the country, and for services provided to a hospitalized beneficiary.
The defendant has been released on her own recognizance after a recent detention hearing pending further court proceedings.
