As the Director of CDR’s Consumer Directed Personal Assistance Program (CDPAP), I want to make sure that anyone using Medicaid funded programs for home care is aware of the intense scrutiny and monitoring that is occurring to identify intentional and unintentional fraud in Medicaid funded programs.

In the case of CDPAP, there are no official regulations from the Department of Health. Agencies are directed to loosely base their program structure on Personal Care regulations from NYS Social Service Law 505.14 and 763.13. For those of you who may not be aware, the Department of Health has issued two Local Commissioners Memorandums, dated June 30, 2006 and November 2, 2006, providing the answers to frequently asked questions related to the administration of CDPAP. These were widely distributed among fiscal intermediaries and local Department of Social Service Districts, if you would like a copy, feel free to contact me at mmenough@rochestercdr.org.

Partly as a result of the lack of official regulations governing CDPAP, there are allegations (heavily promoted by certain members of the traditional home care industry) that fiscal intermediary agencies used by consumers participating in the CDPAP have no oversight and no fraud control measures in place and that fraud runs rampant and unrecognized in CDPAP. This is simply not true.

You should be aware that the Office of the Medicaid Inspector General is charged with the responsibility of identifying fraud in all Medicaid funded programs, prosecuting consumers and attendants who are implicated in making fraudulent claims for payment, and recovering monetary damages. For those of you who may believe that only large home care agencies and nursing homes are being targeted for investigations and you are only a “small fish”, you are gravely mistaken.

Several consumers and attendants across the New York State have been arrested, charged and convicted of making fraudulent claims to Medicaid. This can be considered felony grand larceny if the dollar amount of the claim is over one thousand dollars ($1000). If convicted, consumers and attendants serve time in prison, pay restitution, and are permanently banned from giving or receiving any services in any Medicaid funded programs. For a very recent nursing home arrest right here in Rochester, visit: www.whec.com

The New York State Federal False Claims Act (31 USC 3729 b) imposes liability on any person who submits a claim to the federal government that he or she knows (or should know) is false. There are many examples I could use to illustrate this point, but typically, a good example of this occurs when the Consumer/Self-Directing Other (SDO) and the attendant sign a time sheet for hours that the attendant has not actually worked and submits this false claim to the fiscal intermediary for payment and billing to Medicaid. Provision 31 USC 3729 of the Act also helpfully clarifies the term “knowing” and “knowingly” the terms mean that a person, with respect to information (1) has actual knowledge of the information (2) acts in deliberate ignorance of the truth or falsity of the information or (3) acts in reckless disregard of the truth or falsity of the information, and no proof of specific intent to defraud is required. This means that even “accidental” human error fraud is still FRAUD in the eyes of the Medicaid Inspector General. Do not let this happen to you!

Next month, I will elaborate on more of CDR’s fraud control measures and best practices, I will also introduce you to our state wide association, CDPAANYS. If you want information in the meantime to help you prevent Medicaid Fraud, call our office at (585) 546-7510.