[T]he state auditor has identified improper payments and possibly fraudulent claims made in connection with the Choices for Care program, which provides in-home services for eligible Vermonters.
The auditor’s report details roughly $150,000 in improper Medicaid payments over a 15-month period in 2016 and 2017. The office also found some “suspicious transactions” that may lead to prosecution.
The findings of improper or suspicious payments include:
- Payroll contractor ARIS Solutions Inc. was reimbursed for $78,000 in payments for hours beyond the maximum limit that did not receive necessary state approval.
- $17,000 to $19,000 was paid for home services when a client was in a hospital or nursing home.
- 47 care attendants were paid to work every one of the 457 days reviewed in the audit.
- 98 caregivers were paid for working 20 to 24 hours in a single day.
The auditor offers several recommendations, mostly related to implementing better checks and balances by state agencies and their contractors.
“Prevention is a more efficient and effective means to minimize fraud, waste and abuse rather than trying to recover payments once they are made,” the report says.
In a written response, state officials noted that the $150,000 identified by the auditor represented less than 1 percent of the $24.7 million in Choices for Care payments made during the time period in question.
However, officials acknowledge that there are “opportunities to strengthen” the program.
“The recommendations contained in the report are worthy of consideration and generally achievable,” officials wrote in a letter signed by the heads of the Agency of Human Services; Department of Disabilities, Aging and Independent Living; and the Department of Vermont Health Access.
Choices for Care offers several long-term care options for those who meet certain clinical and financial criteria. Requirements include being at least 18 years old, Medicaid-eligible and living with a “functional limitation resulting from a physical condition … or associated with aging.”
In-home services can be provided by a home health agency. Or Vermonters can hire their own caregivers — who then are paid by the state — via a “consumer- or surrogate-directed option.”
Officials who administer the program said Vermont is a “national leader” in long-term care. And they lauded the availability of consumer-directed home care, saying it saves more than $13 million annually “as compared to the costs of home health agency services.”
Monica Caserta Hutt, commissioner of the Department of Disabilities, Aging and Independent Living, said such “self-directed personal care services” also help address workforce shortages.
“They have been instrumental in making sure that we can maximize the available workforce by enabling care to be delivered by workers who are selected by, and often known to, the program recipients,” Hutt said. “They put control and choice into the hands of program participants and allow them to direct the time and level of care in a way that enhances their independence.”
Auditor Doug Hoffer says those programs have also “given rise to compliance and fraud issues” both nationwide and in Vermont. For that reason, his office focused on consumer-directed, in-home care payments made between July 2016 and September 2017.
After digging through documentation including authorizations, timesheets, payroll and claims, the auditor found approximately $150,000 in improper Medicaid payments. The biggest issue was with consumers who received more than the maximum 720 hours of care allowed by Choices for Care without receiving state approval.
The audit says ARIS Solutions Inc. – a payroll contractor for the Department of Disabilities – “was reimbursed for claims on behalf of 202 consumers for companion/respite care of more than 720 hours in 2016, even though there was no approved variance.” That accounted for about $78,000 in improper payments.
Another $40,000 in improper payment was due to ARIS receiving Medicaid reimbursement for 133 people who had exceeded their budget for in-home care. “Most of the improper payments were for 14 consumers whose (care) budgets were exceeded by more than $1,000,” the audit says.
The audit found $17,000 to $19,000 had been paid for home services when a client was in a hospital or nursing home. Overtime also was an issue. In 395 instances, “ARIS paid an attendant for more overtime than appeared justified by the total hours paid for the week,” the audit says.
The term “improper payments” can apply to reimbursements made in error; it doesn’t necessarily indicate fraud. However, the auditor also found evidence of suspicious activity.
For example, 47 care attendants “were paid to work every one of the 457 days under review,” the audit found. Another 153 attendants worked between 428 to 456 days – which equates to fewer than two days off per month.
Also, in a total of 666 instances, 98 caregivers were paid for working 20 to 24 hours in a single day.
The auditor’s office has referred its data to the state attorney general’s Medicaid Fraud and Residential Abuse Unit, which has “opened several cases based on our analyses and plans to open other cases,” the report says.
That unit’s director was not available for comment Monday. But the auditor’s office acknowledged that there’s no way to know yet whether any fraud actually occurred “because it must be established that an individual falsified a claim and that it was done intentionally to achieve some gain.”
The auditor found that improper payments in the Choices for Care program had three main causes.
One is a continued reliance on manual data entry, especially by ARIS. The report says “payments for unauthorized services and overlapping shifts were largely attributed to ARIS staff mistakes.”
Another flaw is a lack of adequate system edits – defined as “computerized tests to detect inaccuracies in eligibility, reporting and payment.” For example, the audit says ARIS has “no preventive control” to stop payment for in-home care when a client is in the hospital.
The audit also faulted insufficient monitoring. The Department of Disabilities, Aging and Independent Living, for instance, does not systematically compare budgets in consumers’ care plans with actual expenditures.
One fix for such issues is already in the works: The audit noted that federal law requires implementation over the next few years of an electronic visit-verification system. Hoffer said that system “is intended to verify that services billed for home and community-based personal or home health care are for actual visits made.”
Additionally, the audit made recommendations related to keeping a tighter rein on overtime and compensation limits and watching out for signs of fraud and waste.
Program administrators agreed to implement those recommendations. In a statement issued Monday, Hutt said state officials generally were “pleased” with the report.
“They highlighted some areas of concern that we were already aware of and a few new items for us to explore,” Hutt said. “Some of the risks they identified are inherent in a program that is consumer-directed. We can always improve in outreach to consumers, in our systems work and overall.”