Keith Foreman, like a growing number of disabled Americans on Medicaid, qualified for a personal caregiver to help him with daily activities such as dressing, shaving and preparing meals.
Foreman, 57, who has a spinal injury, hired his girlfriend, Sheila McDonald. In 2011, McDonald received almost $5,000 from Medicaid for six months of care she provided to Foreman.
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These personal-care services, which are available in all 50 states, are designed to help the sick, elderly and disabled remain in their homes and out of expensive nursing facilities. But Foreman was not living at home. During the days marked on McDonald’s timesheets, he was housed in the Massac County jail in Metropolis, Ill., serving time for using a stolen debit card at a local liquor store. Foreman and McDonald pleaded guilty to making false statements.
Lax requirements for both caregivers and patients, along with poor state and federal oversight, have made the rapidly growing Medicaid personal-care programs an increasingly lucrative target for fraud, according to a federal report scheduled for release Thursday.
The report, by the Office of the Inspector General of the Health and Human Services Department, brings together six years of OIG investigations and 23 reports. It describes programs hindered by poor claims documentation, insufficient monitoring of claims data for fraud and waste, and a crazy-quilt of requirements for care workers in different states.
In particular, it faults the federal Centers for Medicare & Medicaid Services for inadequate oversight of the programs, whose costs are shared by states and the federal government, as is the norm for Medicaid.
“Historically, CMS has left a lot of the responsibility for overseeing waste, fraud and abuse to the states,” said Christi Grimm, special assistant to the principal deputy inspector general. “As a result, we have 301 different sets of requirements for caregivers across the states.”
Although some states mandate criminal background checks and licensing for home health workers, others lack even the most basic requirements, including age minimums, leading to cases in which juveniles escape prosecution for fraud and abuse, she said.
“We are asking CMS to step up to the plate,” Grimm said.
The report urges the CMS to improve oversight and monitoring of state plans, including standardizing rules for personal-care workers to set minimum age and education levels, and requiring criminal background checks.
In a written response, the CMS — part of the Health and Human Services Department — explicitly concurred with only one of the OIG’s recommendations: that it should provide states with claims data to help root out cases in which recipients are simultaneously receiving institutional care and home health services. As for the recommendation on establishing federal guidelines for personal-care workers, the CMS noted that there is a shortage of attendants.
CMS spokesman Brian Cook said the agency is “working to protect personal care from fraud and abuse by promoting stronger training programs for workers who provide personal care, working with states on background check programs for these workers, and developing new data methods to analyze claims for potential fraud and abuse.”
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