Fraud [ frôd ]
1. wrongful or criminal deception intended to result in financial or personal gain: © Oxford University Press
Fraud occurs when someone intentionally falsifies information or deceives Medicare and Medicaid.
Medicare and Medicaid fraud, waste, and abuse affects every American by draining critical resources from our health care system, and contributes to the rising cost of health care for all. Taxpayer dollars lost to fraud and waste harm multiple parties, particularly some of our most vulnerable citizens.
The U.S. Attorney General Eric Holder has placed the amount of fraud at $60 to $90 billion for Medicaid. If 10% of that number is attributed to In Home Health Care, we are looking at $6 to $9 billion in funds lost that could go to those in need.
HHS’s pay and chase model has been an open invitation to fraud. Catching the scammers after the fact is too late; most of the money is already gone. The government needs to process claims in a way that identifies questionable and improper claims before they are paid.” (Merrill Matthews, Forbes 2012 “It’s always easier to stop it on the front end,” said state Sen. David Sanders, an Arkansas Republican who authored a law establishing a special inspector general for Medicaid fraud. “What you want to try to do is prevent waste, fraud and abuse from happening.” The VCS solution addresses this exact statement.
Billing for Services Not Performed
“This is one of the largest areas of Medicaid provider fraud. A provider tries to bill Medicaid for a treatment, or procedure, or service, which was not actually performed. Examples would be billing for home health care hours when they were not provided.”
Office of the Attorney General of Washington State Website http://www.atg.wa.gov/MedicaidFraud/CommonTypes.aspx#.UzDmFLVOXr
NO ONE IS TO BLAME
Neither the states nor the state departments or the In Home Care Agencies are to blame for the fraud being committed in the In Home Care Industry. The tools necessary to combat errors and omissions as well as intentional deception has not been available until now. Fraud is real and is happening in every state. Companies may not even know the extent to which it is happening to them. The system is too easily manipulated using paper and telephony for companies to identify offenders. The VCS solution takes care of this problem.
The current system of monitoring HCA’s is susceptible to fraudulent activities because there is no identifiable method of validation or verification of time worked or care provided. Pushing buttons on a phone cannot sufficiently identify the caregiver’s identity (who pushed the buttons) and location, nor does it validate that the necessary care services were provided.
When the system relies on a phone call from the HCA, just the reliance on the phone alone can lead to potential problems:
It has been suggested that a landline be required, but about two-thirds of homes in the U.S. no longer have landline phones as people switch to cell phones, prepaid phones or Voice Over Internet Protocol (VOIP) such as Magic Jack, Vonage, Cisco Linksys, Ooma, Polycom and Grandstream.
The use of VOIP phones can’t prove the physical location of a device.
Input errors are easily made on touchtone phones when an HCA pushes the wrong key.
A landline does not prove WHO is inputting the numbers.
In addition, the reliance on a landline phone opens the door to fraud because any of the following could be a valid reason why an HCA did not call in…or a fraudulent reason that could easily pass for truth:
• Phone is disconnected due to nonpayment.
• Patient changed phone number.
• Patient is moving, leading to an interruption of service.
• Patient staying temporarily with another person, such as a family member.
• Patient refuses to let HCA use phone.
• Patient is outside waiting for the HCA, to be transported to a medical appointment.
• Patient requires immediate assistance due to a fall, confusion, incontinence or some other type of emergency.
• HCA can’t enter the dwelling to use the phone because the patient is asleep and not answering the door.
• Patient must admit HCA into a secure building.
Employing 21st century technology to fight fraud
Obviously there’s plenty of room for improvement when it comes to verifying and validating both HCA time and the care provided. A better solution would enable time management for the HCA as well as validated paperwork for the state. Such a solution would provide daily electronic reporting, as well as adhere to the rules and regulations of Medicaid, HIPAA and the FLSA. It would be a mobile solution that enables easy auditing and lowers the cost of verifying and validating HCA’s. It should not be a solution that relies on outdated landline phones, the integrity of HCA’s, or expensive manual recordkeeping.
A technology-based solution can eliminate the need for landlines and the potential for fraud. Such a solution can simply verify and validate the following using biometrics and capturing data in real time:
• Shift start time
• Time between HCA and patient sign in
• Tasks performed
• Shift stop time
• Mileage driven
• Total hours worked for the week and month by HCA’s.
• Total hours of eligibility left for clients.
• Daily task sheet signed by client and HCA
• HCA certification eligibility
• GPS time stamping
It’s time to do away with the outdated system and the fraud it enables
Many elderly and disabled depend on good in-home personal care, and would have to move to an institution without it. They are healthier and live longer when at home, and we have a social responsibility to use government funds wisely to ensure that they can receive the care they require. However, when an underlayment of fraud exists (as it currently does), those who most need the care are the ones who are punished by the system because they don’t receive it. In addition, we have ever tighter government budgets, and fraudulent billings to Medicaid steal from the taxpayers and those who do honest work. The whole monitoring system must aid in the prevention of fraud by utilizing the highest degree of verification and validation made available with today’s technology.