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Personal care services have been under scrutiny recently with several fraud cases and a recent Office of Inspector General report asking New Jersey to pay back $145 million in claims that did not meet federal or state requirements.


In the December 2011 report, OIG said that 36 of the 100 sample claims did not meet at least one requirement including prior authorization, nursing supervision and personal care assistants receiving in-service education. Fourteen claims had more than one deficiency, the report stated.


For its part, New Jersey’s program, which defines personal care services as household chores and some health-related duties, disagreed with OIG’s findings.


Personal Care Services Charges for Others


In other states, attorneys general have filed criminal charges against people allegedly involved with personal care services fraud.


In North Carolina, 10 people were charged with submitting fraudulent timesheets for personal care services worth more than $59,000, the attorney general stated Dec. 19. Three others were charged with billing Medicaid $376,000 for personal care services that were not provided.


In Missouri, a woman was charged with six felony counts of Medicaid fraud for allegedly submitting claims for personal care services that she did not provide, the state’s attorney general said Dec. 6.


In Louisiana, a woman was charged with 13 counts of Medicaid fraud for filing claims for services, such as bathing and cooking, at times that the patient was receiving treatment at a hospital, the state’s attorney general said Oct. 25.


While RACs have not posted personal care services issues, contractors could be on the lookout in this potentially vulnerable area.


Inpatient RAC issues posted


RAC Region A posted 15 inpatient hospital issues last week ranging from an MS-DRG for other injury, poisoning and toxic effect diagnosis with major complications and comorbidities to an MS-DRG for hip and femur procedures except major joints with complications and comorbidities.


For more about the RAC issues, see the chart below.

Click to view PDF


About the Author

Karen Long is the compliance product manager for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation’s leading independent authority on home healthcare business, regulation and reimbursement.


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