The National Consumer Protection Technical Resource Center: The Center of Service & Information for SMPs

Health Care Fraud

From the Office of Inspector General (OIG), U.S. Department of Health & Human Services

Personal Care Services Fraud

A personal care attendant can be a great help to seniors who need assistance with their daily living and routine activities. However, not all companies that provide these services are honest. Personal care attendants are covered by most state Medicaid programs but only where the beneficiary is disabled or has a qualifying chronic medical condition. Help can include activities of daily living such as bathing, eating and dressing. Also, they may help with administration of medications. NOT included is help with cleaning activities and daily chores such as lawn mowing and gardening. Care may only be rendered by state-certified individuals.

How the Scam Works

  • There are several methods by which fraud may occur. An attendant may be billing for time when he was not actually there or when performing not-covered services such as maid services.
  • Incidents of personal theft of the beneficiary’s belongings, credit cards or other items of value.
  • False certification of need by a physician who is not the beneficiary’s doctor.
  • “Sharing” a Medicaid payment between a non-qualifying beneficiary and the personal care attendant or her company as a bribe or kickback.

How to Fight Back

  • Review the billing or timekeeping document that your caregiver/attendant asks you to sign. Make sure the information on those documents accurately reflects both the hours the caregiver has spent assisting you and the activities she has performed for you.
  • Prior to receiving personal care services, a physician must certify that you truly need the services. Make sure it is your primary care physician who is ordering your services. Absent special circumstances, only your primary care doctor or other doctor who is very familiar with your health and medical history is qualified to determine whether you are eligible to receive personal care services paid by Medicaid.
  • Also keep in mind that unless you truly meet the eligibility requirements for this program, you are not entitled to have Medicaid pay for personal care services. Do not allow these scam companies to talk you into pretending or falsely certifying that you need assistance with activities of daily living when you do not.

Report Suspected Fraud

To report suspected fraud, click here.

 

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