Federal Government Finds Fraud and Abuse in Care Assistant Programs

Personal care assistants (PCAs), offered through most state Medicaid programs, help families manage day-to-day care of children, adults and the elderly with special needs.

PCAs come to the home and assist with many daily tasks, from eating and bathing to grocery shopping. Many of them deliver excellent care, and the services they provide allow people with disabilities and chronic conditions to remain in their homes and communities, which is usually a better environment than institutions and nursing homes.

However, PCAs do not always do the job they were hired to do and sometimes their neglect can lead to serious and even fatal injury to the patient.  The Office of Inspector General (OIG) at the Department of Health and Human Services recently issued a report that summarized federal investigations into more than 200 instances of fraud and patient neglect in PCA programs across the country since 2012

The findings are timely because the U.S. Department of Labor projects that demand for personal care assistants will grow by 26 percent over the next eight years.

Typically, PCAs are employed by an agency that works with the Medicaid program to provide services. Not all PCA providers are hired through an agency, however.  Many states allow friends,   family members and others to serve as PCAs. 

Variety of Cases

The OIG found many cases of fraud, with claims submitted for services that were not necessary or never provided.

One of the cases cited in the OIG report involved PCAs in Washington State who billed a state program for visits that were never made to a beneficiary; one of the claims was for a period when the individual was out of the country.

In another case, the owners of a PCA agency in Alaska allowed their employees to submit false time sheets for services that were not provided to Medicaid recipients.

In addition to cases involving fraud, the OIG also found several cases where the patient was harmed or neglected.  Some incidents were so significant that the patient needed hospitalization or died as a result.

In one case, an Idaho woman was hospitalized for severe dehydration and malnourishment.  Her son, who was employed as her PCA, reportedly neglected her care.  When authorities searched their home, they found it was filthy and littered with drug paraphernalia, trash and dog feces.

The OIG has called on the Center for Medicare & Medicaid Services (CMS), which oversees Medicaid across the country, to issue regulations that will help detect improper payments and “reduce the risk of beneficiaries being exposed to substandard or otherwise harmful care.”

One of the problems is that patients are often reluctant to report neglect or improper care by PCAs.  In many programs, PCAs have little to no supervision, with the patient usually responsible for supervision.  Many patients with disabilities are not able to monitor PCAs.

Some of the OIG’s recommendations include: establishing minimum standards for PCAs, including background checks; requiring PCAs to register with the state; and requiring more detailed information on claims.

The OIG report does acknowledge that CMS issued a booklet in 2014 for PCA providers on preventing Medicaid improper payments, and the agency plans on issuing further information to address vulnerabilities in the PCA system.  But CMS is also aware of disability groups' fears that stricter regulation could compromise access to caretakers.

To read the OIG report, click here.

For a Kaiser Health News article on the report, click here.

For a recent Government Accountability Office report on the personal care assistant program, click here.