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Transcript for the audio podcast:
Personal Care Services: Trends, Vulnerabilities, and Recommendations for Improvement
A Portfolio

From the Office of Inspector General of Department of Health and Human Services

https://www.oig.hhs.gov

[Roberta Baskin] I'm Roberta Baskin, Director of Media Communications for the Office of Inspector General, and I'm speaking with Christi Grimm, the Special Assistant to the Principal Deputy Inspector General about Personal Care Services - Trends, Vulnerabilities, and Recommendations for Improvement. Christi, this is such an important topic. Just first explain what "personal care services" are and about OIG's work in this area.

[Christi Grimm] So, personal care services involve activities of daily living like bathing, light housework, and meal preparation. It's an optional Medicaid benefit that's designed to provide assistance to those who want to remain in their homes and communities. Currently all 50 States offer personal care services.

[Roberta Baskin] What about Medicare? Does Medicare also cover personal care services?

[Christi Grimm] No. The services are only offered under Medicaid, and at a States' discretion. States have considerable flexibility in how they design and operate their Medicaid programs. Historically, the Centers for Medicare and Medicaid Services (or CMS), the agency that administers Medicaid, has left most of the responsibility for ensuring that's there is no waste or abuse in the program largely to the states. In fact, CMS does not require that care attendants have any specific qualifications. They're not required under Federal law to register with States in advance of providing the care. There are no specific documentation requirements for personal care. And States can design their own billing practices so that in some States you can't even identify who the care attendants are, when the claims are submitted for payment.

[Roberta Baskin] How much work has the Office of Inspector General done to get a sense of where the vulnerabilities are?

[Christi Grimm] We have a very large body of work in this area. Since 2006, we have produced 23 audits and evaluations.

[Roberta Baskin] Given that enormous body of work, what makes this Portfolio different?

[Christi Grimm] The Portfolio is new and basically synthesizes findings from OIG's audits, evaluations, and investigations and provides comprehensive recommendations for improvement. We're very excited about this new means to capture everything we've learned to create a full picture about the integrity of a program.

[Roberta Baskin] Give us a big picture of personal care services. What are the trends you're seeing?

[Christi Grimm] First, there's a great deal of growth. In 2011 Medicaid costs for these services totaled approximately $12.7 billion, more than a one third increase since 2005. The Department of Labor has projected that employment of personal care and home health aides will grow by 46 percent by 2018, which is much faster than the average of 10 percent for other occupations.

[Roberta Baskin] What else did you find?

[Christi Grimm] We're also seeing large percentages of improper payments. The error rates found in our audits have ranged upward of 40% in the State of New Jersey. And such high error rates are not unique to that one State. In New York we found that 32 percent of claims were paid in error. And in Washington, we saw that 20 percent of payments were improper.

[Roberta Baskin] Those are incredibly high error rates. What do you mean when you say the payments were "improper?"

[Christi Grimm] It can mean many things. The payments were not supported by documentation that was required by the State. The services were not authorized by a clinician. Or, the services were for periods where Medicare was paying for nursing home, hospital, or other institutional care. We don't think it likely that the beneficiary could be in two places at once to justify payment for personal care services and hospital care.

Payments were also improper when attendants didn't even meet their own State's qualifications like having to be a certain age or attaining a specific education level.

[Roberta Baskin] So attendant qualifications are a crucial focus of this Portfolio report. Why such an emphasis?

[Christi Grimm] Well, states are generally responsible for designing and operating their individual Medicaid programs. When we looked at the different qualification requirements, we found 301 different expectations.

[Roberta Baskin] More than 300 different expectations in 50 states. That alone seems incredible.

[Christi Grimm] And we even found differences within the same state for expectations. And that level of variation is worrisome, and we recommended that CMS, as the oversight agency, create minimum qualification standards to create more consistency.

[Roberta Baskin] What about fraud trends? What kinds of schemes have been seen by OIG's Special Agents and the many State Medicaid Fraud Control Units?

[Christi Grimm] Our investigators report that the increasing volume of fraud involving personal care services has become a top area of concern. Common fraud schemes involve conspiracies between attendants and beneficiaries - where beneficiaries accept cash or other benefits in exchange for participating in the fraud scheme.

OIG is also encountering new schemes in States that send payments for attendants, directly to the beneficiaries. We are now seeing prosecutions involving cases in which the beneficiaries submit false claims for services that were never provided. And then in these cases, the States send payments directly to the beneficiaries, and then the beneficiaries forge the attendants' name and put the money into their bank account.

[Roberta Baskin] Well, of course the flip side of this is that there are consequences for vulnerable beneficiaries. Give us a sense of some of those cases.

[Christi Grimm] A majority of Medicaid beneficiaries interviewed during two of our audits reported quality of care issues. The most serious cases involved physical abuse or threats, property theft, and patient abandonment. One beneficiary reported that an attendant abandoned her on two separate occasions, once in the street and once in the subway because the attendant's shift had ended.

[Roberta Baskin] Given the range of serious problems with oversight, what recommendations is the OIG making to the Centers for Medicare and Medicaid Services for improvements?

[Christi Grimm] The Portfolio basically asks that CMS do more to protect against the vulnerabilities we found in Medicaid personal care services. For instance, we ask that they reduce that significant variation in attendant qualification standards so that beneficiaries are better protected from receiving suboptimal care.

[Roberta Baskin] What about billing problems?

[Christi Grimm] We ask that CMS and States improve their ability to monitor billing and care quality. That attendants enroll or register with the State, and that unique identifiers for attendants appear on the claims along with specific dates when services are provided.

We also ask that CMS provide States with the data and guidance they need to prevent improper payments. For instance, we ask that CMS make certain that States have enough Medicare data to be able to tell if Medicare paid for a hospital stay during the time when personal care services were being billed to Medicaid.

[Roberta Baskin] Thank you Christi Grimm, part of a team of auditors, evaluators, and investigators committed to identifying Medicaid improvements. And as we said at the beginning of this podcast, this is an important service in health care and growing. Thanks for producing this new body of work and showcasing what needs to be done to improve the care and oversight.

[Christi Grimm] Thank you Roberta.

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