Personal care providers face state inquiries

State Medicaid investigators are looking into more than 80 criminal allegations of fraud, forgery, or theft by workers or companies who offer personal care services such as bathing, dressing and feeding people in their homes.

The state Attorney General's Office said this week that half the investigations were opened during the past two years and that the overall number has more than doubled in the past five years.

Almost half of all Medicaid fraud referrals involve personal care services, with the rest involving hospitals, pharmaceutical companies, medical professionals, home health care workers, nursing home workers and the like, the Attorney General's Office said.

The state agency that oversees Medicaid services separately concluded 120 civil investigations into companies that improperly supplied personal care services, resulting in the state's asking for $1.8 million back.

"The number of investigations into these matters has increased steadily each year," Noelle Talley, a spokeswoman for the Attorney General's Office, said in an e-mail message. "According to our Medicaid fraud folks, fraud referrals in [personal care services] have been rising faster than fraud referrals in other areas."

Tim Rogers, head of the Home and Hospice Care Association of North Carolina, said the state's review of personal-care services agencies, following restructuring two years ago, is "stronger and more diligent than for any other care setting."

"The association never condones ... any kind of fraud and abuse," Rogers said. "We would encourage the state to adopt some of the same practices in other settings."

Some investigations and convictions concern cases in which care workers submitted time sheets that falsely showed they worked with clients. In other cases, workers were accused of stealing from clients. And in the civil cases companies are being told to reimburse the state for services that were unnecessary or never delivered. In a Guilford County case, a certified nursing assistant submitted false billing records that showed she was giving personal care services to people on Medicaid, resulting in her conviction on 15 counts of Medicaid provider fraud, according to court records.

"We are also looking at the quality of care delivered to recipients," said Lynne Testa, assistant director for program integrity at the Division of Medical Assistance, which oversees Medicaid. "If the quality of care is also suspect, we will address those issues."

Medicaid paid for personal care services for more than 53,000 North Carolinians last year, at an estimated cost of more than $300 million. Use of in-home services is growing fast because "people want to live in their homes and die in their homes with dignity," Rogers said. The services are intended to help people with daily life, keeping elderly and disabled clients at home and out of expensive long-term care.

When the system is exploited, it can mean that companies are paid for work that isn't done, some recipients get care when they don't merit it and others get less care than they should because of absent or neglectful workers.

"There are cases in which it's totally and completely appropriate," said John Faulkner, a physician's assistant who runs rural health clinics in several Eastern counties. "About every day I sign off on about three or four agreements to provide personal care services. The requests say someone needs to lay their clothes out, someone needs to shave them, someone needs to bathe them, and it's not always true."

State budget negotiators are considering requiring a second doctor's approval before a client can receive Medicaid-paid personal care services at home. That change could save the state as much as $3 million in Medicaid costs annually, but that doesn't count the costs of putting it in place, Rogers said.

"What bothers me is the nurses who are doctoring up the assessment, and very often the patients are acting like they are worse off than they are," said Faulkner. "I will call the patient back to my office and say 'I'm worried, you sound like you are a lot worse off than you are.' "

When a person wants personal care services, a company gets an order from a doctor to have an registered nurse assess the person. If the person meets Medicaid's guidelines, the nurse prepares a plan of care, which the doctor must approve. The client has to be reassessed at least once annually.

In the criminal cases handled by the Attorney General's Office, successful prosecutions of direct-care workers occurred in Cumberland, Hoke, Guilford, Bertie, Sampson and Pasquotank counties. The care workers typically received suspended sentences or probation, but had to make restitution in amounts ranging from a few hundred dollars to more than $5,000. In the Guilford County case, the worker, Tarsha Slade, got probation and was ordered to pay back $2,302.

"I can confirm that one or more PCS companies are under investigation, but we cannot discuss those investigations at this time," Talley said.

Calls to personal care companies were not returned Thursday.

Sen. Tony Rand, the Senate majority leader, has introduced a bill that would increase penalties for Medicaid fraud and create a new mechanism for whistleblowers. It has been on the agenda for two meetings of a Senate judiciary committee this week, but has not been discussed.