Alyssa Schafer

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Recently in the news, you have probably happened on a few stories focused on Medicaid fraud. Some of these involve doctors or hospitals, but many focus on fraud and waste in home and community-based services. Just last week in fact, a woman in Wichita, Kan., was ordered to repay more than $19,000 to the Kansas Medicaid program and was sentenced to 12 months of probation with an underlying sentence of 6 months in prison.

At Paraquad, my title is Consumer Directed Services timesheet compliance manager. That is a long, fancy title that basically means most of my job is to catch potential misuse, waste and fraud that may be occurring in our Consumer Directed Services program and report it to MO HealthNet, the Missouri Attorney General’s office and the Missouri Department of Health and Senior Services.

Consumer Directed Services (CDS) is Missouri’s version of the program referenced in the article above about Kansas. It allows someone with a physical disability to hire a personal care attendant of their choosing to assist them with their daily personal needs. Attendants and program participants track the time that is work and submit it to Paraquad for payment. Paraquad then bills Medicaid on the participant’s behalf.

At a glance, having one person devoted to the task of detecting potential misuse makes it sound like there is a lot of fraud occurring in this program. This is not the case.

While we do catch a handful of truly fraudulent claims each year, they are far and few between.  Most of what I turn in to the three state agencies above turns out to be the result of human error or a training issue. The vast majority of personal care attendants provide quality care that allows people with disabilities to stay in their homes.

So what is Medicaid fraud?  How can it be avoided? Can the fraud be committed accidentally? What are the consequences? What should you do if you know or suspect someone is committing fraud? Why is it important for you to report someone if  you think they are committing fraud? These are all questions I am asked on a regular basis and what I hope to answer for you here.

The Missouri Attorney General’s office defines Medicaid fraud as a “(misrepresentation of) services rendered (that) thereby increases the reimbursement from Missouri Medicaid.” There are many different types of fraud that can occur in this broad definition.

Many of them do not apply to a Consumer Directed Services program but instead apply to doctors or hospitals. However, the premise is the same. The website of the Missouri Attorney General’s office lists several examples of what it considers to be fraud. The one I see the most is someone billing for services that were not actually performed. In the case of CDS, this means a personal care attendant and participant submit a timesheet to Paraquad for payment for time the attendant did not actually work.

Avoiding fraud is easy: Don’t do it. Don’t misrepresent services provided. Don’t turn in a timesheet if your attendant did not actually work, was working somewhere else or was completing tasks that were not authorized on your care plan. If a timesheet is filled out accurately every day the attendant works, it is quite impossible to commit fraud.

Committing Medicaid fraud is considered a felony. It is punishable by probation, hefty fines and prison time. Someone who commits Medicaid fraud also puts themselves in jeopardy of losing the privilege of receiving Consumer Directed Services at any point in the future. A person convicted of committing Medicaid fraud may never be allowed to work in any healthcare-related field for the rest of their life.

Reporting Medicaid fraud can seem intimidating, but it is very important. The more people who report suspected fraudulent activity, the higher the integrity of all Medicaid-based programs.  The more reports that are made, the more waste, misuse and fraud can be caught.

I often hear that some social programs should not exist because of “all the fraud” that happens within them. Once people who are misusing these programs are reported on and caught, people who are actually in need of the services and use them appropriately can continue to enjoy life in their homes and communities (rather than the alternative of going into a nursing home or other care facility) without the threat of having their services cut because someone else is doing the wrong thing. We never know when we may personally need assistance so we all have a responsibility to uphold the integrity of all social programs by doing our part to prevent and report potential misuse.

If you suspect someone is committing fraud (whether in a home and community-based service setting, in your doctor’s office or anywhere else you may her about it, please contact your state’s Attorney General’s office, Medicaid office or Department of Health and Senior Services. Most will have Medicaid fraud control units to specifically handle your call.

Alyssa Schafer is the Consumer Directed Services (CDS) Timesheet Compliance Manager at Paraquad.  She can be reached at aschafer@paraquad.org.

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