Law enforcement agencies and government regulators need new tools to effectively combat fraud within Pennsylvania's $33 billion Medicaid program, according to a grand jury report released Monday.
Community based health-service programs can be "easily manipulated to facilitate fraud" because they lack the supervision, training and oversight that exist in traditional residential health care facilities, the report made public by the attorney general's office said.
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The jurors said the person who actually provides a service should be specifically named in requests for reimbursement and be given a unique identification number. Requests should state the time and date the service was provided, and service providers should have to undergo training in quality care and proper billing practices, the report said.
Jurors requested the wider investigation into Medicaid after handling fraud investigations, the report said.
It described allegations that an unlicensed psychiatrist provided services and prescribed controlled substances, that the mother of a severely disabled girl with autism directed her daughter's support staff to do household chores, and that a personal care attendant billed two agencies for services performed on the same date and at the same time.
"To be sure, these examples involve unscrupulous actors," said Attorney General Josh Shapiro at a news conference to discuss the report. "But the system let them get away with it for far too long."
The jury recommended lawmakers require standard training in proper care, proper billing practices and reporting of critical incidents and fraud.
"The failure to mandate standardized training for individuals providing services results in incomplete, inaccurate or conflicting information," the report said.
Without such training, jurors wrote, provider agencies can get away with fraud by blaming individuals who perform the services.
State prosecutors said all three recommendations — the ID number, time and date of service and better training — are in place in at least some other states.
Pennsylvania's Medicaid program provides health care and social services for people who meet low-income eligibility guidelines, including children, the elderly and the disabled.
Together, the elderly and disabled amount to 29 percent of Medicaid recipients, but 69 percent of the costs in Pennsylvania.
The state's Medicaid spending last year was just over $33 billion, with about two-thirds of that coming from the federal government, according to the Department of Human Services.
The rest is paid through the state's general tax collections and with tobacco settlement money, state lottery revenues and provider assessments.
Currently, more than 2.8 million Pennsylvanians are covered.
The attorney general's office said its Medicaid Fraud Control Unit made 164 arrests last year, obtained 105 convictions and recovered more than $22 million.