Testimony Before the United States House of Representatives 
Committee on Energy and Commerce 
Subcommittee on Oversight and Investigations 
 
 
 
 
 
Combating Waste, Fraud, and Abuse  
in Medicaids Personal Care Services Program 
 
Testimony of: 
Christi A. Grimm 
Chief of Staff  
Office of Inspector General  
Department of Health and Human Services 
 
 
 
 
May 2, 2017 
10:15 a.m. 
Location: Rayburn House Office Building, Room 2322 
   
      Testimony of: 
Christi A. Grimm 
Chief of Staff 
   Office of Inspector General, U.S. Department of Health and Human Services 
 
 
 
Good morning, Chairman Murphy, Ranking Member DeGette, and other distinguished 
Members of the Subcommittee.  I am Christi Grimm, Chief of Staff of the Office of Inspector 
General (OIG) of the U.S. Department of Health and Human Services.   
Thank you for the opportunity to appear before you to discuss the importance of 
protecting Medicaid personal care services (personal care or PCS) from fraud, waste, and abuse 
and protecting the beneficiaries who rely on those services from abuse and neglect.  OIG has an 
extensive body of work examining vulnerabilities in PCS and recommending improvements to 
address the lack of program integrity safeguards, high improper payments, and health and 
safety vulnerabilities.  Safeguarding beneficiaries and the Medicaid PCS program through better 
program integrity continues to be one of OIGs top priorities.   
In the last 5 years, OIG has opened more than 200 investigations involving fraud and 
patient harm and neglect in the PCS program across the country.  Sadly, some of these cases 
have involved loss of life and serious harm to Medicaid beneficiaries who are especially 
vulnerable.  These include cases like the elderly woman in Idaho who was hospitalized to treat 
malnutrition and dehydration because the caregiver failed to provide water and food.  When 
investigators served a search warrant suspecting she was a victim of neglect, they found that 
she had been living in filth despite the fact that Medicaid was paying a PCS attendant to care for 
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  her everyday needs.  Or the Pennsylvania beneficiary with autism who died of exposure to the 
cold while under the care of an attendant.  The attendant lost the beneficiary in a crowded 
store and waited an hour to notify authorities.  
These are just two of the heartbreaking stories that no one should ever experience, 
regardless of the State they live in or what type of personal care services they receive.  OIG is 
testifying today to highlight the important needs that an effective Medicaid PCS program serves 
and identify ways to help the program better fulfill that potential.  Systemic problems related to 
the design and delivery of Medicaid PCS must be rectified so that the Federal Government can 
help prevent similar tragedies from happening in the future and better combat fraud, waste, 
and abuse.  My testimony today will highlight: our work overseeing the PCS program; the 
problems we have identified; our recommendations for improvement; and the progress to 
date.   
Background on Medicaid Personal Care Services 
 PCS enable Medicaid beneficiaries who are elderly, have disabilities (including children 
with disabilities), or have chronic or temporary conditions to live with as much independence as 
possible in their homes and communities, rather than in nursing homes or institutions.  The 
services provided by PCS attendants include a broad range of nonmedical services to support 
Activities of Daily Living  bathing, dressing, toileting, and personal hygiene.  PCS can also offer 
support for Instrumental Activities of Daily Living, such as meal preparation, money 
management, shopping, and telephone use.   The services place providers directly in the homes 
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  of our most vulnerable beneficiaries, heightening the risk of fraud and abuse of the program, 
and abuse or neglect of the beneficiary. 
While PCS is an optional Medicaid benefit, all States provide this benefit to some 
Medicaid beneficiaries in their State under their State plan or through home- and community-
based services waivers.  PCS are generally provided under either an agency-directed or self-
directed model.  Under an agency-directed model, a personal care agency is an enrolled 
Medicaid provider and employs personal care attendants to provide services in beneficiaries 
homes.  Under a self-directed model, the beneficiary or their representative has the 
responsibility for managing the delivery of PCS, including hiring the personal care attendant.  
These options allow States to have significant flexibility when designing PCS programs to meet 
the needs of their beneficiaries.  As a result, States often have several different programs that 
provide PCS to a wide range of Medicaid beneficiaries. 
Recent data suggest that PCS will continue to grow rapidly, partly because of the aging 
baby boom population.  For example, the U.S. Department of Labor, Bureau of Employment 
Statistics, in its Occupational Outlook Handbook, 20162017 edition, projected that 
employment of personal care aides will grow by 26 percent from 2014 to 2024.  This growth is 
faster than the average for all occupations.  As of 2012, more than 3.2 million beneficiaries 
relied on personal care, and in fiscal year 2014, Federal and State spending on personal care 
totaled $14.5 billion, or about 18 percent of Medicaids spending on home- and community-
based services.  Growth in personal care and other home- and community-based services has 
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  come about, in part, to fulfill the mandate of the United States Supreme Court in its decision in 
Olmstead v. L.C., 527 U.S. 581 (1999) to help individuals with disabilities to live and be cared for 
in their homes and communities whenever possible.   
PCS Program Vulnerabilities 
For the past 8 years, OIG has identified program integrity for home- and community-
based services, particularly PCS, as a top management concern.  We have issued more than 30 
audits and evaluations, recommending the recovery of over $700 million and improvements to 
service delivery.  OIG, often in partnership with the State Medicaid Fraud Control Units (MFCU), 
has investigated hundreds of PCS fraud schemes.  Our work demonstrates the persistent 
vulnerabilities in PCS that contribute to high improper payments, significant fraud, and that 
place vulnerable beneficiaries at risk for abuse and neglect.    
OIGs October 2016 Investigative Advisory on Medicaid Fraud and Patient Harm 
Involving Personal Care Services summarized various PCS fraud schemes OIG has seen in 
Federal investigations.  These cases show that PCS fraud takes many forms.  Common schemes 
involve payments for PCS that were unnecessary or not provided.  Some PCS investigations 
have uncovered schemes organized by caregiving agencies that involve numerous attendants 
and beneficiaries, while other investigations have targeted individual attendants and the 
beneficiaries these attendants claim to serve.  
 
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  For example, in 2016 OIG investigated a PCS attendant who submitted duplicate time 
sheets to claim payment for services not rendered to multiple clients with developmental 
disabilities.  Although Medicaid was paying the PCS attendant to clean and cook for the clients 
and help integrate them into the community, some clients lived in squalor.  The PCS attendant 
also endangered clients by driving while impaired by pain pills.  Increased data and internal 
controls would have revealed that services were not being provided to the beneficiaries.  
Federal qualifications and screening standards would have revealed the attendants own 
substance abuse problems, providing beneficiaries and their families with valuable background 
information with which to make care decisions.   
MFCUs are often on the front lines of investigating fraud in PCS.  MFCUs regularly report 
PCS as a top fraud concern; between fiscal years 2012 and 2015, approximately one-third of 
their convictions involved PCS attendants.  OIG consistently partners with MFCUs to combat 
PCS fraud across the country.  In June 2016, OIG participated in a National Health Care Fraud 
Takedown and partnered with 24 MFCU offices on health care fraud issues, including Medicaid 
PCS fraud.  OIG has ongoing work exploring MFCUs efforts to combat PCS fraud.  We expect to 
issue the results this summer.     
Although MFCUs are vital in the fight against fraud because of their position on the front 
lines, they are limited in their ability to investigate allegations of patient abuse or neglect by 
personal care attendants.  MFCUs lack the authority to investigate Medicaid patient abuse or 
neglect that occurs in a home- or community-based setting.  A legislative change is needed to 
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  expand MFCUs statutory mission to include the investigation of abuse and neglect in 
beneficiaries homes.  
OIGs November 2012 Personal Care Services: Trends, Vulnerabilities, and 
Recommendations for Improvement (PCS Portfolio) summarized the findings of OIGs body of 
work on PCS and made recommendations to improve program vulnerabilities.  OIG found that 
PCS payments were often improper because the services did not comply with basic 
requirements.  OIG also found that there were inadequate controls in place to ensure proper 
payments and quality of care.  PCS services and controls vary significantly from State to State 
because of a lack of Federal requirements for PCS and PCS attendants.  This lack of consistency 
across and within States regarding the use of internal controls and qualifications makes it 
difficult to effectively pursue fraud and abuse in the PCS program.   
Prevention, Detection, and Enforcement of PCS Fraud and Abuse 
OIGs long history of oversight and enforcement has demonstrated that to effectively 
combat fraud, waste, and abuse and safeguard beneficiaries, action must be taken to 
prevent bad actors from participating in our programs, 
detect potential fraud, waste, or quality concerns quickly, and 
enforce the laws of these programs through Federal and State investigations and 
prosecutions of fraudulent and abusive practices. 
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  OIGs work has consistently demonstrated that these basic pillars of program integrity 
are lacking in PCS.   
Prevent.  First, there is a lack of basic Federal qualifications for PCS attendants.  As a 
result, the Government does not consistently know who they are doing business with and 
cannot effectively prevent bad actors from serving beneficiaries and billing the Medicaid 
program.  PCS places attendants directly in the homes of elderly or disabled beneficiaries who 
may be particularly vulnerable, creating a real risk of patient abuse and neglect.  Requiring all 
PCS attendants to meet basic, minimum qualifications, such as having a State identification 
card, minimum age requirements, and a background check, better ensures that only qualified 
attendants are providing care.  Requiring these minimum qualifications also ensures that 
necessary steps are being taken to prevent bad actors from committing fraud and harm in this 
important program.  Some States currently require these basic safeguards in some of their PCS 
programs, but not in others.  It is important that States have flexibility to implement various 
types of PCS to appropriately tailor these programs to the specific needs of their beneficiaries.  
However, that flexibility must be balanced with the need to provide all beneficiaries with the 
protections of these basic safeguards.  Thus, OIG continues to recommend that CMS establish 
minimum Federal qualifications and screening standards for all PCS attendants. 
Detect.  Second, PCS attendants are not required by Federal law to be enrolled as 
providers or otherwise registered by States.  As a result, we lack consistent information across 
States on who is actually entering the beneficiarys home.  Without this critical information, we 
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  cannot quickly identify and investigate a bad actor, including those who have engaged in fraud 
or abuse in other States.  A single PCS attendant may provide services to multiple beneficiaries, 
putting each of them at risk.  In addition, that same PCS attendant may have fraudulently 
claimed reimbursement for services not actually provided by billing for services provided to 
multiple beneficiaries at the same time.  Without knowing the individual who is providing the 
services to a beneficiary, detecting fraud and abuse is severely hampered.  Accordingly, OIG 
continues to recommend that CMS require States to enroll or register all PCS attendants and 
assign them unique numbers.  This information will make it possible to protect beneficiaries 
and identify potential fraud more quickly, and assure that minimum qualifications are met.  
Enforce.  Third, to mitigate improper payments and fraud in PCS, OIG recommends that 
CMS require that PCS claims identify the dates of service and the PCS attendant who provided 
the service.  When States have adopted measures that make available better data about PCS, it 
has a dramatic effect on the ability to identify and take action to stop fraud, waste, and abuse.  
For example, Alaska implemented a requirement that all PCS attendants be enrolled with the 
Medicaid agency.  This allowed the Alaska MFCU and the Alaska Program Integrity Unit to 
compare and match provider information against other data, such as Medicaid claims.  Having 
that provider data available significantly improved their capability to investigate bad actors.  In 
a short span of 2 years, that type of data analysis helped support 108 criminal convictions and 
led to $5.6 million in restitution.  It also had a sentinel effect that helped the State reduce its 
PCS costs from $125 million in 2013 to $85 million in 2015.    
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  As this example shows, better data leads to better enforcement and reduced costs.  The 
savings achieved through better program integrity could provide funding for increased services 
to a larger number of beneficiaries in need, increasing access to critical care.  Access to reliable 
national PCS data allows fuller visibility into the program operations, vulnerabilities, and even 
best practices.  In addition, service-specific PCS data are critical to ensuring that oversight and 
enforcement efforts are able to find fraud, waste, and abuse quickly and protect vulnerable 
beneficiaries from harm.   
21st Century Cures includes some promising steps forward to safeguard beneficiaries 
and makes better data available for the PCS program by requiring that all States implement 
electronic visit verification systems (EVVS) by 2019.  The law requires that EVVS collect 
information on who receives and who provides the service; the service performed; and the 
date, time, and location of the service.   As States begin implementing these new requirements, 
it will be important to ensure that the data gathered is complete, accurate, and timely.   
As the PCS program grows and evolves, OIG continues to recommend that CMS consider 
whether additional controls are needed to ensure that PCS are allowed under program rules 
and are provided. 
Progress in Implementation of OIG Recommendations 
Notwithstanding progress, much remains to be done.  To date, four PCS 
recommendations remain unimplemented, and two have been implemented.    
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  OIG has worked with CMS to explore actions that it can take to address vulnerabilities in 
the delivery of PCS.  CMS has issued an informational bulletin, Strengthening Program Integrity 
in Medicaid Personal Care Services (December 2016), that summarizes program integrity 
vulnerabilities and highlights safeguards States can use right now to strengthen program 
integrity in PCS.  In addition, CMS has issued guidance, entitled Preventing Medicaid Improper 
Payments for Personal Care Services (July 2016), describing steps that PCS agencies and 
attendants can take to prevent improper payments.  CMS also issued a Request for Information 
(RFI) entitled Federal Government Interventions to Ensure the Provision of Timely and Quality 
Home and Community Based Services (November 2016).  CMS conducted a series of trainings, 
webinars, and conferences with States.  These activities outlined approaches for States to 
identify overpayments.  As a result, OIG closed the two recommendations related to adequate 
prepayment controls and data States need to identify when beneficiaries are receiving 
institutional care paid for by Medicare or Medicaid.   
We have four recommendations that remain unimplemented: 
1.  Establish minimum Federal qualifications and screening standards for PCS workers, 
including background checks. 
2.  Require States to enroll or register all PCS attendants, and assign them unique numbers. 
3.  Require that PCS claims identify the dates of service and the PCS attendant who provided 
the service. 
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  4.  Consider whether additional controls are needed to ensure that PCS are allowed under 
program rules and are provided. 
The RFI sought stakeholder comments, information, and data on policy options that 
CMS can consider to address issues affecting home- and community-based services, including 
PCS.  CMS has indicated that it is currently analyzing the comments it received to determine 
potential policy options.  Depending on the actions CMS chooses to take, these 
recommendations could be resolved.   
Conclusion 
OIG work has demonstrated that PCS is subject to persistent fraud and beneficiary 
harm.  CMS, in partnership with States, must implement basic safeguards to preserve this 
critical benefit that allows millions of beneficiaries to remain in their homes and communities.  
Combatting fraud and abuse in PCS not only protects beneficiaries and programs, but it also 
elevates the many honest, professional, and dedicated care attendants that enable 
beneficiaries to live independently.  OIG is committed to the program integrity of home- and 
community-based services and ensuring beneficiary health and safety.  To achieve that goal, 
OIG will continue to work with CMS and partner with other oversight agencies like MFCUs, the 
Department of Justice, the Administration for Community Living, and the Department of Health 
and Human Services Office of Civil Rights.    
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