Fraud, a five letter bad word!

             Headlines across newspaper front page scream PCA Fraud! Doesn’t it makes you want to cringe and yell out, “We are not all bad providers!” 
I have worked for a Fiscal Support Entity (FSE) for the past 10 years, specifically with the Personal Care Attendant (PCA) program along with other self-directed programs. Over time I have seen, both suspected and confirmed cases of fraud. Each time fraud is suspected, you hope it’s not true. But an investigation takes place, a report is made with the State and the questioning begins. While cases of fraud are few and far between it does happen. But, with each case it makes a provider tighten their policies and practices to ensure it does not happen again.
               While it feels as if we read or hear about a new fraud case each month, the following fraud facts might surprise you. Within the state of Minnesota there are 240,000 enrolled providers, some examples are PCA’s, pharmacists, transportation providers and day care providers. Over all there are 100 different provider types. For each person enrolled, the Department of Human Services (DHS) will authorize a unique identifier which is used for billing. The billing for Medicaid services is overseen by the Office of Inspector General (OIG). Currently OIG oversees provider billing for the $12 billion dollars Medicaid industry in Minnesota, this fact came from a recent Senate hearing in which the DHS and the OIG reported their findings on PCA Fraud.
             Within this same report, OIG indicated in 2016 there were 361 completed fraudulent investigations. Out of these 361 completed reports only 189 were related to PCA fraud, so this accounts for 52% of the fraud cases within Minnesota. Also 2016, according to the Bureau of Labor Statistics there were 67,420 workers employed as personal care aides for recipients of Home and Community Based Services in Minnesota. If we do some math comparing the 189 cases of fraud compared to the amount of workers this breaks down to 0.002%.
                On a national level, Applied Self Direction (a national organization focused on technical assistance for self-directed services) conducted a study in 2015 and reported there were 536 indictments for fraud, waste or abuse of Personal Care Services out of the more than 2 million PCA’s working throughout the nation. That calculates to 0.03%, or if you want look at this in another way, it breaks down to 1 in every 4,500 PCA’s.  
                As a Fiscal Support Entity; our staff looks at every timesheet, every signature, and every receipt that comes in to ensure accuracy and to avoid any potential fraudulent activity. Fiscal Support Entities or PCA agencies have policies in place to report suspected fraud or training for workers upon hire and annually on what constitutes fraud in an effort to minimize activity. Both PCA agencies and Fiscal Support Entities have to pass rigorous requirements with the state in order to provide services.
                So while the news would have us believe that there are fraud cases running rampant across the county, the facts indicate a relatively low percentage. While there may be a case from time to time, over all services are being provided without problem.

Written by: Julie Lux, MRCI