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The ProviderTrust Blog

Your source for healthcare compliance news, advice from industry experts, and all things related to OIG exclusions.

OIG, Medicaid, Medicare, Fraud and Abuse, department of justice

The OIG is Serious About Personal Care Fraud: Cruisin’ for a Bruisin’

Posted by Michael Rosen, ESQ on Thu, Apr 20, 2017

The OIG has heard and seen it all, right? It is hard to imagine the daily insanity of discovering and investigating fraudulent behavior within the healthcare industry. One thing is for sure; they are not messing around.

Given the evolution of technology as it pertains to personal care, pursuing fraud is becoming more complex and despite how tricky schemers may believe they can slip by - the OIG remains diligent in its goal to hold providers accountable.

Home Health Services Fraud

Ask yourself, do you need to be present to provide "in-home" health services? Or can you be on a cruise enjoying the sun and fun, yet bill Medicare for such in-home direct patient care? Six St. Louis, Missouri home health care workers and patients were charged with making false statements to Medicaid regarding home healthcare services that were neither received nor provided. Read more about this story from the U.S. Department of Justice website. All of the indictments involve allegations that the defendants made false statements in Medicaid time sheets. These statements explained that particular patients and workers provided or received personal care services (e.g. grooming, cleaning, feeding, and medication assistance) in the home setting during certain dates and times when, in reality, the patients or workers were somewhere else.

Personal care services is a booming sector within home health these days. The concept is that some basic life skills and services would benefit individual patients that need the basic care. The services typically include things that the patient cannot perform due to an injury, illness or age. As such, they depend on people to come to their home and help them with these everyday needs. However, the industry has seen its fair share of taking advantage of the system for pecuniary gain.

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The OIG’s Response

This case presents two interesting concepts.  First, the OIG has been aggressively pursuing fraud in the personal care services' sector. This quickly emerging area in home health care has caught the attention of the OIG in recent years and is even addressed as a focal point of investigation in the 2017 OIG Work Plan.

Second, the indictment is against providers and patients that allegedly participated in the fraudulent billing scheme together. To date, most cases have been pursued against the company and/or its employees. The addition of indicting patients is a twist and indication of a possible scheme perpetrated by both parties.

Fraud can be perpetrated in many fashions. Sometimes by providers and sometimes in conjunction with a patient. The OIG is serious about pursuing fraud against those who are involved in it.  The personal care industry has presented ample ground for fraud and is on the radar of the OIG and DOJ.


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ProviderTrust Co-Founder, mrosen@providertrust.com | Connect with Michael on Linkedin 


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