Personal Care Assistants are the fastest Growing Occupation in the US

Personal Care Assistants Help Millions of Chronically Ill, Disabled, and Elderly Patients

Federal and State Regulations governing Medicare and Medicaid have created a unique class of worker in the United States Healthcare System. Personal Care Assistants (PCAs) will comprise over 1.2 million workers by 2018 and currently provide over 1.2 billion hours of care to elderly, disabled, and chronically ill patients. By 2020 PCAs will be providing more hours of care to a select group of patients with Disabilities, Diabetes, COPD, Alzheimer’s, Parkinson’s, and conditions associated with old age, then ALL of the physicians in the US providing care to the ENTIRE US patient population.

A majority of PCAs work as ”independent providers” employed by the patient and reimbursed under a Medicaid consumer directed program. PCAs may also be affiliated with a Medicare / Medicaid Intermediary (Home Health Agency).

It is estimated that PCAs account for over $25 billion in direct payments from Medicare and Medicaid. Furthermore, by providing over 25 million hours of care per week, PCAs influence over $100 billion annually in healthcare services (pharmaceutical, DME, etc…), shopping / dietary decisions, personal care, and financial decisions for the patients under their care. To date, the influence of PCAs on patient decisions in the healthcare provider hierarchy has been overlooked and underestimated.

A high level of Medical Fraud is associated with PDAs

Government regulations, an aging population, and increasing incidence of chronic disease are driving the growth of the PCA workforce at an unprecedented rate. As the number of hours of care provided to patients by PCAs is increasing, so to, is the incidence of fraud. The FBI, State Agencies, and healthcare organizations are attempting to address fraudulent Medicare and Medicaid billing on behalf of PCA services. A June 5, 2014 indictment in Illinois netted over 43 Medicare and Medicaid beneficiaries as well as Personal Care Assistants that were billing for services that never occurred.

According to an Office of Inspector General report released in December 2012, Medicaid costs for personal care services in 2011 totaled $12.7 billion, a 35 percent increase since 2005. The U.S. Department of Labor projects that the employment of personal assistants and home health care workers will grow by 46 percent by 2018. U.S Department of Health and Human Services, Office of Inspector General: Personal Care Services, Trends, Vulnerabilities, and Recommendations for Improvement, OIG-12–12–01 (November 2012). Home personal care is one of the fastest growing job categories in the country. However, the OIG’s report points to numerous problems in Medicaid personal care services that leave it vulnerable to improper payments, abuse, and fraud, including lack of training standards, uneven oversight of services provided, and failure to implement prepayment controls to prevent improper or fraudulent payments.

“Nationwide, the biggest fraud problem in the Medicaid program has these personal assistant programs which represent the number one fraud complaint to state Medicaid fraud units,” said Stephen Wigginton, U.S. attorney for the Southern District of Illinois.”

Personal Care Assistants should receive better access to education and increased wages commensurate with experience to elevate outcomes in our healthcare system Fraud detection is a critical component.

The “personal choice option” also known as “consumer directed care” in Medicare and Medicaid regulations allows PCAs to be chosen by patients. Fraud is a significant concern in care provided by PCAs in consumer directed care. In fraud cases, a patient will select an in-direct family member or a friend and agree to split some portion of the reimbursement. The fraudulent “PCA” does not even have to show up at the patient’s residence and time sheets are forged. The Medicare and Medicaid reimbursement rates for PCAs are approximately $20 per hour.

Fraud remains a looming concern in home care; the US Government Accountability Office reported “estimated improper payments for Medicare of almost $48 billion for fiscal year 2010,” including expenditures for home oxygen and other home health claims. To qualify for coverage from payers or to generate incentives within insurance for individuals, home care technologies may also offer new avenues to address home care fraud, in addition to improving patients’ health and quality of life and saving money.

Franchised Home Health Care Agencies are fast pace. The leading franchises in terms of number of locations or “units” are Home Instead, Comfort Keepers, Home Helpers, and Visiting Angels. These four brands account for about 2,400 locations. The largest franchises in terms of corporate revenue are Home Instead, Interim Health Care, Visiting Angels and Comfort Keepers. Some of these organizations have expanded their networks internationally. Home Instead is considered to be not only the leading senior care franchise but also the largest franchise system period in the U.S. And in 2010, Comfort Keepers made it onto the Inc. 500 list of the top 500 fastest‐growing companies in the U.S. with a three‐year sales growth of 32 percent.[1]

I have discovered numerous national and local home health companies committing Medicaid Fraud in the Philadelphia area.

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