Seeking to reduce fraud, new grand jury report calls for fixes to Pa.’s Medicaid program

By: - April 15, 2019 5:30 pm

PA Attorney General Josh Shapiro is one of a growing class of activist state attorneys general nationwide. (Capital-Star file photo)

Mandated training and other fixes would expand the tool chest of options available to state officials and law enforcement officers as they seek to prevent and combat fraud in Pennsylvania’s Medicaid program, a grand jury report released Monday has revealed.

“We all want to ensure that people get the highest quality care possible,” Pennsylvania Attorney General Josh Shapiro, whose office oversaw the grand jury, said during a news conference at his Harrisburg office.

The grand jury’s recommendations, which stemmed from Medicaid fraud prosecutions by Shapiro’s office, call for three changes:

  • Requiring service providers who do not have what’s known as a “national provider identifier” to obtain a state identification number, as is the case in Ohio. They would also be required to include that number on every claim for payment, making them easier to track.
  • Requiring providers to go through mandated, standardized training on their job duties and how to properly bill for their services.
  • Requiring all state Medicaid forms to include both the date, as well as start and end times when a service is provided. Right now, that level of specificity is not required.

All three recommendations would require legislative authorization.

Shapiro declined to say when and where the grand jury met. But he did say the panel considered evidence from “six case that illustrate … deficiencies in the system.”

One such case dealt with a person who was working for three behavioral health agencies at the same time, even as that person worked as a substitute special education teacher. Shapiro said that person would “submit timesheets claiming that she was providing services that overlapped with each other and with her work as a teacher.” According to Shapiro, the grand jury concluded the fraud would have been caught sooner if the perpetrator had been required to include specific dates and times for her services.

A second case cited by Shapiro dealt with the mother of a child with autism who ordered the child’s caregivers to perform such unrelated services as running household errands, feeding the family dog, and even painting her house. If those workers had standardized training, and knew their specific job duties, the violations would not have occurred, grand jurors concluded.

Shapiro said the Pennsylvania Department of Human Services, which administers Medicaid in the state, is “doing the best it can with current laws, but we can always make the laws stronger.”

The agency was given an advance copy of the grand jury report and was allowed to comment on its findings, Shapiro said. Legislative leaders were also given a copy of the report, as well as the response from the Human Services department.

In its response letter, Human Services officials said they “appreciate[d] and welcome[d] the report’s recommendations,” and that they planned to “strive to implement workable policies and procedures to reduce fraudulent conduct and prevent the depletion of limited resources.”

According to Associated Press reports, Pennsylvania’s $33 billion Medicaid program obtains about two-thirds of its funding from the federal government. The rest comes through state tax collections, tobacco settlement money, revenue from the Pennsylvania state Lottery, and assessments on service-providers. The program, which is known as “Medical Assistance” in Pennsylvania, provides services to about 2.8 million people, including the elderly and children.

Shapiro said his Medicaid Fraud unit made 292 arrests resulting in 173 convictions and recovered $34 million for the state in 2017.

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