Attorney General Josh Shapiro Announces Grand Jury Recommendations for the Pennsylvania Medicaid Program

April 15, 2019 | Topic: Criminal

HARRISBURG — Attorney General Josh Shapiro today announced recommendations from a statewide Grand Jury investigation into the Pennsylvania Medical Assistance (MA) Program. The legislative actions recommended by the Grand Jury aim to assist the Pennsylvania Department of Human Services in identifying and preventing fraud from occurring in the program and provide law enforcement, particularly the Pennsylvania Office of Attorney General’s Medicaid Fraud Control Section, with the tools it needs to effectively investigate fraud within the program.

The Pennsylvania Medical Assistance—or Medicaid—program is implemented by the Department of Human Services and provides care to more than 2.7 million low-income Pennsylvanians. The Office of Attorney General’s Medicaid Fraud Control Section is dedicated to prosecuting anyone who defrauds the MA Program through unlawful billing or failing to provide services to those whom the program serves.

In the 2017 and 2018 calendar years, the Medicaid Fraud Control Section made a total of 292 arrests, achieved 173 convictions, and recovered more than $34 million for the commonwealth, making it the third highest ranking Medicaid fraud control unit in the country. Last month, the Section was nominated and selected for the U.S. Inspector General’s Award for Excellence in Fighting Fraud, Waste, and Abuse.

“Medicaid provides essential care to some of Pennsylvania’s most vulnerable citizens, including low-income individuals, children with serious health conditions, and individuals suffering from substance use disorder,” said Attorney General Josh Shapiro. “When bad actors take advantage of the system, they deny these people the care they deserve, take advantage of hard-working care providers, and scam Pennsylvanians out of their hard-earned tax dollars.”

This investigation stemmed from two independent Medicaid Fraud investigations that prompted the Grand Jury to conduct an investigation into how to identify and prevent fraud and ensure delivery of satisfactory care within the MA Program.

The Grand Jury heard testimony from state regulators, law enforcement officials, managed care organizations (MCOs), and health care providers about the MA program. They identified the following three systemic issues within the MA program that permit the exploitation of care-dependent Pennsylvanians for financial gain and impact the quality of care provided:

  1. The MA system does not currently require the individual providing services to be identified on the claim submitted for payment.
  2. MA claims submitted for payment do not require specific date and time information before payment is made.
  3. The individuals providing these services lack the knowledge and training to provide quality care and to properly bill for those services.

The Grand Jury heard evidence from six cases that illustrate these deficiencies in the system. In one case, an individual who was simultaneously working for three behavioral health agencies and as a substitute special education teacher would submit timesheets claiming she was providing services which overlapped with each other and/or her work as a teacher. The Grand Jury concluded that her fraud would have been caught sooner if there had been a mandate that the claims identify her as the individual providing the services and include specific dates and times of the services.

In a second case, a mother of a daughter with autism was directing her daughter’s caregivers to provide unauthorized services such as painting the house, feeding the dog, and running household errands. She was also instructing the workers to report their services incorrectly and falsely reporting that her husband and son provided services. The Grand Jury concluded that if the program had a standardized training module, the workers would have been able to identify that they were being required to document their services improperly and that the tasks assigned to them were not authorized. They would have also been more informed about how to report these violations.

The Grand Jury provided the three following recommendations to address these deficiencies. The Grand Jury asserted its belief that these recommendations will assist DHS in carrying out its mission and will provide the MFCS with the tools it needs to effectively combat fraud, resulting in increased criminal convictions and recoveries:

  1. State Provider Identifier (SPI): The legislature should enact a statute mandating that any individual seeking to provide services paid for, in whole or in part, with MA funds who does not have a National Provider Identifier (NPI) be required to register with the Commonwealth of Pennsylvania and obtain a SPI prior to the performance of said services. The legislation should mandate that every claim for MA services identify the actual individual providing the services by requiring that the providing individual’s NPI or SPI be placed on every claim.
  2. Date and Time Specificity: The legislature should enact a statute mandating that every claim for MA services document every date that a service was provided as well as the start and end times for each date of service.
  3. Standardized Training: The legislature should require that DHS establish and mandate standardized training for all persons providing services utilizing SPI. The standardized training should be specific to the type of services being provided and focus on the required level of care the recipient is to receive and what services are appropriately billable under that program. The training should also provide information on how to contact Protective Services and where to report fraud within the MA program.  The standardized training for each specific type of service must be completed prior to providing services.

“Working with our partners in Governor Wolf’s Department of Human Services, we’re dedicated to doing everything in our power to ensure that the Medical Assistance Program runs as effectively as possible and minimize its vulnerability to fraud,” said Attorney General Shapiro. “I am grateful for the work of the Grand Jury to develop comprehensive, manageable recommendations for how to identify and prevent fraud in the program. These recommendations will make it easier for law enforcement to protect Pennsylvanians and for DHS to make sure people are getting the care they need.”

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