Department of Health and Human Services
OFFICE OF 
   
INSPECTOR GENERAL 
 
 
 
 
 
 
 
 
 
I C
NAPPROPRIATE  LAIMS FOR 
 
M   P C
EDICAID  ERSONAL  ARE 
 
S  
  ERVICES
 
 
 
 
 
Daniel R. Levinson  
Inspector General 
 
December 2010 
OEI-07-08-00430    
   
 E X E C U T I V E   S U M M A R Y  
OBJECTIVES
 
To determine whether Medicaid claims for personal care services (PCS) 
were inappropriate because (1) attendants qualifications were 
undocumented or (2) providers had no record of serving the 
beneficiaries. 
BACKGROUND 
Medicaid is a joint Federal and State program that provides medical 
assistance to low-income and medically needy individuals.  At their 
option, State Medicaid programs may provide PCS in a beneficiarys 
home or other community-based setting.  PCS attendants provide the 
elderly and people with disabilities with the assistance they need to 
remain in their homes and communities.  Combined State and Federal 
Medicaid expenditures for PCS totaled $9.9 billion in 2006, an increase 
of 20 percent since 2004.  
States are required to institute provider safeguards to protect the 
health, welfare, and safety of Medicaid beneficiaries receiving PCS.  
One of the ways that States can fulfill this requirement is by 
establishing PCS attendant qualifications, such as requiring criminal 
background checks and establishing minimum age, health status, 
education, and training requirements.  A 2006 Office of Inspector 
General report found that PCS attendant qualifications frequently 
differed among the programs within a State.1   
We selected a stratified random sample of 450 Medicaid claims for PCS 
provided from September 1, 2006, through August 31, 2007, in 
10 States.  Eight of the ten States required that attendants 
qualifications be documented.  For each sampled claim, we requested 
documentation to determine whether the attendant(s) who provided the 
PCS met all required qualifications.  To produce a conservative estimate 
of error, we accepted a wide variety of documentation and considered 
attendants qualified if they met at least one component of a 
qualification.     
 
1States Requirements for Medicaid-Funded Personal Care Service Attendants, 
OEI-07-05-00250, revised December 2006.   
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E X E C U T I V E   S U M M A R Y  
FINDINGS 
Attendant qualifications were undocumented for 18 percent of 
Medicaid PCS claims, resulting in $724 million in inappropriate 
payments.  Eighteen percent of paid PCS claims (6.5 million) in our 
universe were inappropriate because attendants qualifications were 
undocumented.  From September 1, 2006, through August 31, 2007, 
Medicaid paid approximately $724 million for these claims.  The 
qualifications most often undocumented were background checks, age, 
and education.   
For 2 percent of Medicaid PCS claims, respondents had no record of 
serving the beneficiaries.  Respondents for 2 percent (552,578) of paid 
Medicaid PCS claims in our universe reported that they had no record of 
ever providing services to the beneficiaries named in the claims data.  
From September 1, 2006, through August 31, 2007, Medicaid paid 
approximately $63 million for these inappropriate claims. 
RECOMMENDATIONS 
Medicaid inappropriately paid $724 million for 18 percent of the PCS 
claims in our universe because the attendants qualifications were 
undocumented.  Further, Medicaid paid an additional 2 percent of 
Medicaid PCS claims in our universe inappropriately because the 
respondents had no record of providing services to the beneficiaries.  In 
light of these findings, the Centers for Medicare & Medicaid Services 
(CMS) should: 
Ensure that Medicaid claims for PCS provided by attendants with 
undocumented qualifications are not paid.  CMS could work with 
States to ensure that agencies and attendants are aware of attendant 
qualifications and documentation requirements, and to ensure that 
State Medicaid programs have a method to verify that qualifications are 
met. 
 
Take action regarding the inappropriate claims identified in our review.  
We will forward information regarding the inappropriate claims we 
identified to CMS in a separate memorandum.  CMS may want to work 
with States to recover the Medicaid payments for PCS provided by 
unqualified attendants and/or attendants for whom we received no 
documentation to support that they met qualifications in States that 
require such documentation.  CMS may want to pay particular attention to 
  OEI-07-08-00430  INAPPROPRIATE CLAIMS FOR MEDICAID PERSONAL CARE SERVICES  ii    
   
E X E C U T I V E   S U M M A R Y  
the inappropriate claims for which respondents said they had no record of 
ever serving the beneficiaries named in the claims data. 
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
CMS concurred with both recommendations.  In response to the first, 
CMS described plans to work with States to ensure that Medicaid 
claims for PCS provided by attendants who do not meet States 
qualifications are not paid.  CMS indicated it will work through the 
State plan amendment and waiver review process, and other 
educational and communication opportunities, to address this 
recommendation.  In response to the second recommendation, CMS 
stated it will review the information regarding the inappropriate claims 
we identified and take action based on that review.  We made technical 
corrections to the report based on CMSs comments. 
 
  OEI-07-08-00430  INAPPROPRIATE CLAIMS FOR MEDICAID PERSONAL CARE SERVICES  iii   
 
 T A B L E   O F   C O N T E N T S  
EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i
 
 
I N T RO DUC T IO N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 
 
 
F I N D IN G S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 
Attendant qualifications were undocumented for 18 percent of 
Medicaid PCS claims, resulting in $724 million in  
inappropriate payments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 
For 2 percent of Medicaid PCS claims, respondents had no  
record of serving the beneficiaries.  . . . . . . . . . . . . . . . . . . . . . . . . 11 
 
 
R E C O MMEN D A T ION S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 
Agency Comments and Office of Inspector General Response . . . 13 
 
 
APPENDIXES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 
 
A:  Point Estimates and Confidence Intervals. . . . . . . . . . . . . . . . 14 
B:  Types of Attendant Qualifications and Documentation 
Requirements Established by States. . . . . . . . . . . . . . . . . . . . 16 
C:  Details of Documentation Received and Office of Inspector  
General Analysis Criteria To Substantiate Attendant  
Qualifications   . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 
D:  Agency Comments  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 
 
 
A C K NO WL E D G M E N T S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 
 
    
   
 I N T R O D U C T I O N  
OBJECTIVES 
To determine whether Medicaid claims for personal care services (PCS) 
were inappropriate because (1) attendants qualifications were 
undocumented or (2) providers had no record of serving the 
beneficiaries. 
BACKGROUND 
Medicaid is a joint Federal and State program that provides medical 
assistance to low-income and medically needy individuals.  States 
establish Medicaid eligibility requirements, benefits packages, and 
payment rates under standards set by the Centers for Medicare 
& Medicaid Services (CMS).   
State Medicaid programs may provide PCS in a beneficiarys home or 
other community-based setting.2  PCS attendants provide elderly 
beneficiaries and beneficiaries with disabilities with the assistance they 
need to remain in their homes and communities.  These attendants 
assist beneficiaries with nonmedical activities such as bathing, 
dressing, light housework, medication and money management, meal 
preparation, and transportation.3  States can provide Medicaid PCS 
through their State plans,4 through one or more waivers,5 or both.  
Combined State and Federal Medicaid expenditures for PCS totaled 
$9.9 billion in 2006, an increase of 20 percent since 2004.6  
Furthermore, the Congressional Budget Office (CBO) projects a 
$2.6 billion increase in Federal expenditures for Medicaid PCS by 2015.   
 
2 Social Security Act,  1905(a)(24), 42 U.S.C.  1396d(a)(24); Social Security Act, 
 1915(c)(1), 42 U.S.C.  1396n(c)(1); State Medicaid Manual, Pub. No. 45,  4480(A). 
3 PCS do not include skilled nursing or home health care, physical therapy, occupational 
therapy, speech and language therapy, medical social services, or the provision of durable 
medical equipment or other medical supplies and services.  State Medicaid Manual, 
Pub. No. 45,  4480(C).   
4 Social Security Act,  1905(a)(24), 42 U.S.C.  1396d(a)(24); Social Security Act, 
 1915(i), 42 U.S.C.  1396n(i); Social Security Act,  1905(a)(7), 42 U.S.C.  1396d(a)(7).   
5 Waivers allow the States more flexibility in the way they administer their Medicaid 
programs and can be requested under sections 1115, 1915(c) and 1915(i) of the Social 
Security Act.  Social Security Act,  1115, 42 U.S.C.  1315; Social Security Act,  1915(c), 
42 U.S.C.  1396n(c). 
6 Form CMS-64 summary data for 2004 and 2006.  These were the most recent 
CMS-64 data available at the time of our review.  Accessed at http://www.cms.hhs.gov/ on 
February 24, 2010. 
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I N T R O D U C T I O N  
PCS Attendant Qualifications 
States are required to institute safeguards to protect the health, 
welfare, and safety of Medicaid beneficiaries receiving PCS.7  One of the 
ways States can fulfill this requirement is by establishing qualifications 
for PCS attendants.8 
Each State has one State plan; States can have multiple waivers of 
different types.9  Attendants who provide care to beneficiaries through 
State plans and waivers must meet the qualifications specified in the 
State plan, unless they are stated differently in a waiver.10  The State 
Medicaid Manual gives examples of attendant qualifications, such as 
passing criminal background checks and minimum levels of age, health 
status, education, and training.11   
Attendants providing care to beneficiaries who receive PCS through 
1915(c) waivers must meet the qualifications established by those 
waivers.  The State Medicaid Manual requires that States providing 
PCS through 1915(c) waivers establish adequate qualifications to 
ensure that attendants rendering services meet applicable State 
licensing and certification requirements, but does not provide specific 
examples of qualifications for 1915(c) waivers.12   
Attendant qualifications can have multiple components.  For example, 
to be qualified, attendants may have to meet minimum health 
qualifications, which could include passing a physical examination and 
a tuberculosis test.  Table 1 illustrates the types and examples of 
attendant qualifications States have established.    
 
7 Social Security Act,  1905(a)(24), 42 U.S.C.  1396d(a)(24); Social Security Act, 
 1915(i)(1)(H), 42 U.S.C.  1396n(i)(1)(H); Social Security Act,  1915(c)(2)(A), 42 U.S.C. 
 1396n(c)(2)(A). 
8 Other examples of ways that States ensure the health, welfare, and safety of Medicaid 
beneficiaries receiving PCS include establishing requirements for reviews of beneficiaries 
plans of care and supervision of services provided. 
9 The Social Security Act authorizes multiple waiver authorities to allow States flexibility 
in operating Medicaid programs.  For example, Section 1115 of the Social Security Act can 
be used to approve projects that test policy innovations that would otherwise violate 
Medicaid requirements; section 1915(c) waivers can be used to allow long-term-care services 
to be delivered in homes and in community-based settings.  States choose which waivers 
they wish to apply for; some States have no waivers. 
10 Social Security Act,  1115(a)(1), 42 USC  1315(a)(1). 
11 State Medicaid Manual, Pub. No. 45,  4480(E). 
12 State Medicaid Manual, Pub. No. 45,  4442.4. 
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I N T R O D U C T I O N  
Table 1:  Examples of PCS Attendant Qualifications 
 
Type of Qualification  Examples of Qualifications 
Initial training:  Attendant must complete a standardized training course, including subjects such 
as universal precautions, resident rights, safety and emergency procedures, record-keeping, 
nutrition, and assisting clients with bathing and grooming. 
Training 
Continuing training:  Attendant must maintain cardiopulmonary resuscitation and first aid 
certifications, and complete refresher training on subjects similar to initial training 
 (typically annually). 
Attendant must pass a State or national criminal background check; attendant must provide 
Background check  personal or professional references; attendant must be absent from State abuse and neglect 
registries or State and Federal exclusion lists. 
Age  Attendant must meet a minimum age requirement (typically 18) on the date of service. 
Attendant must be free of infectious or contagious disease; attendant must pass a physical exam 
Health 
by a doctor; attendant must be physically able to perform duties. 
Literacy:  Attendant must be able read and write, follow instructions and maintain records; 
attendant must be able to communicate with supervisor and patient. 
Literacy or education 
Education:  Attendant must have completed a minimum level of education (typically a high 
school diploma or General Educational Development (GED) certificate). 
Transportation:  If duties include driving the beneficiary to errands or appointments,  
attendant must have a valid driver's license and current automobile insurance;  
attendant must pass a motor vehicle records check. 
Other 
Employment status:  Attendant must complete immigration forms and employment agreement. 
Performance reviews:  Attendant must pass an annual performance review. 
Source:  Office of Inspector General (OIG) analysis of State PCS attendant qualifications, 2010. 
State Documentation Requirements 
While there were no Federal requirements for documenting PCS 
attendant qualifications, 8 of the 10 selected States required PCS 
providers to maintain documentation showing that the attendant 
qualifications were met.  In these States, claims for services provided by 
attendants whose qualifications were undocumented were 
inappropriate.  Some of the eight states had requirements for 
maintenance of documentation in personnel files; others required 
maintenance of documentation as part of provider certification 
processes.  The remaining two States did not have documentation 
requirements. 
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I N T R O D U C T I O N  
Related Reports 
OIG has issued six reports on PCS services since 2006.  A 2006 OIG 
report found that, unlike qualifications for similar direct-care 
professions such as certified nurse aides, PCS attendant qualifications 
frequently differed among the programs within a State.13  The other five 
reports identified inappropriate and/or vulnerable payments for PCS.  
One report identified over $275 million in improper PCS payments over 
2 years because of noncompliance with requirements for exams by 
medical professionals, for nursing assessments and supervision, and for 
physicians orders.14  Another report identified Medicaid payments of 
nearly $500,000 in five States over 3 months for PCS billed during 
periods when beneficiaries were institutionalized and an additional 
$11 million in Medicaid payments over 3 months vulnerable to payment 
error because beneficiaries may have been institutionalized when the 
PCS were billed.15  A related report found that four States paid 
Medicaid PCS claims billed in excess of 24 hours per day, and that some 
States billing practices created vulnerabilities to inappropriate 
payments for PCS.16  Finally, two reports identified approximately 
$500,000 and $610,000, respectively, over 2 years in improper payments 
for PCS provided while beneficiaries were institutionalized or for PCS 
services that were either insufficiently documented or unauthorized.17, 
18 
 
13States Requirements for Medicaid-Funded Personal Care Service Attendants, 
OEI-07-05-00250, revised December 2006.  This report found that States had established 
301 sets of requirements nationwide, and that wide variations existed within the six most 
common types of qualifications.  For example, a background check requirement in one 
program could include conducting a national criminal background check, checking abuse 
and neglect registries, and/or checking Federal or State exclusion lists; in another program, 
the background check requirement could include checking only references. 
14 Review of Medicaid Personal Care Services Claims Made by Providers in New York 
City, A-02-07-01054, June 2009. 
15 Payments Made in Error for Personal Care Services During Institutional Stays, 
OEI-07-06-00620, August 2008.  Three of the States reviewed used billing practices that 
made it impossible to determine exactly which days PCS were provided.  A single claim 
might bill all PCS provided to a beneficiary in an entire month.  If the beneficiary also had 
an institutional stay during that same month, we could not determine whether PCS were 
provided during the institutional stay. 
16 Medicaid-Funded Personal Care Services in Excess of 24 Hours per Day, 
OEI-07-06-00621, October 2008. 
17 Review of Personal Care Services Claimed by The Center for Living and Working, Inc., 
A-01-06-00011, October 2007. 
18 Partnership Review of Medicaid Claims Processed by Cerebral Palsy and Stavros for 
Personal Care Attendant Services Provided to Beneficiaries During Inpatient Stays,  
A-01-08-00001, November 2008. 
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II NN TT RR OO DD UU CC TT II OO NN   
The Government Accountability Office has issued two reports on issues 
related to PCS since 1996.  The first found that slightly over 
one-quarter of States require criminal background checks on some types 
of home-care workers (including attendants), though these checks are 
generally limited to a States own criminal records.19  The second report 
concluded that Federal oversight of 1915(c) waivers, through which 
States can provide PCS, should be strengthened.20 
METHODOLOGY 
Scope   
We reviewed Medicaid claims for PCS in 10 selected States:  California, 
Florida, Georgia, Illinois, Iowa, Nebraska, New York, Ohio, Tennessee, and 
West Virginia.  We selected these 10 States because they represented 41 
percent of national Medicaid spending on home health and PCS in 2006; 
California, Iowa, and New York spent more on home health and PCS than 
any other type of long-term care in 2006.21 
The 10 selected States provided PCS though 4 State plans and 46 waivers.  
Hereinafter we will refer collectively to the 50 State plans and waivers as 
programs.  We included claims for PCS provided through 45 of  
the 50 programs in our review.  We excluded five programs that included 
PCS as part of a capitated or daily rate because specific payments for PCS 
could not be identified.  Each of the 10 States had from 1 to 8 programs 
included in our review.   
We included all Medicaid PCS claims paid for services provided through 
the 45 programs from September 1, 2006, through August 31, 2007.  This 
was the most recent 12-month period for which claims data were available 
at the start of our data collection.   
 
19 Long Term Care:  Some States Apply Criminal Background Checks to Home 
Care Workers, GAO/PEMD-96-5, September 1996.  Accessed at http://www.gao.gov/archive/ 
on June 17, 2008. 
20 Long Term Care:  Federal Oversight of Growing Medicaid Home and 
Community-Based Services Waivers Should be Strengthened, GAO-03-576, June 2003.  
Accessed at http://www.gao.gov/archive/ on June 17, 2008. 
21 The Henry J. Kaiser Family Foundation, Distribution of Spending on Medicaid 
Long-Term Care, Fiscal Year 2006.  Accessed at http://www.statehealthfacts.org/ on 
June 10, 2008.  OIG analysis of expenditure information available from StateHealthFacts 
shows that three of the selected States spent more on home health and PCS than any other 
type of long-term care.  StateHealthFacts does not report information on PCS expenditures 
alone. 
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I N T R O D U C T I O N  
Selection of Sample Claims 
From each of the 10 selected States, we obtained Medicaid Management 
Information System paid claims data for PCS provided from September 
1, 2006, through August 31, 2007, for the 45 programs included in our 
review.  We also obtained Medicaid eligibility data for the beneficiaries 
who received PCS during this period.  We used this information to 
identify the program through which each beneficiary received PCS. 
To create a universe of claims for the 10 selected States, we combined 
into one file all of the PCS claims data that met our study parameters 
for the 12-month review period.  The combined Federal and State 
expenditures for these claims totaled $4.3 billion.  We created three 
strata based on the payment amount for each claim:  $0.01 to $115, 
$115.01 to $440, and greater than $440.22  We randomly selected 
450 claims distributed among the strata as shown in Table 2.  These 
stratum ranges and sizes were determined to produce the best 
statistical precision.  We projected our findings to the 10-State universe 
of PCS claims that met our study parameters using the sample weights 
from the stratified sample selection.  Statistical projections cannot be 
made to individual States from the sample we selected.   
Appendix A presents the point estimates and confidence intervals for all 
statistics. 
Table 2:  Sample Stratification 
Claims in  Claims in 
Stratum  Payment Amounts
Universe Sample 
1  $0.01$115  24,386,563  140 
2  $115.01$440  12,211,854  200 
3  Greater than $440  770,749  110 
     Total  N/A  37,369,166  450 
Source:  OIG analysis of Medicaid claims data, 2010. 
Identification of Attendant Qualifications and Documentation Requirements 
We consulted with Medicaid officials in the 10 selected States to 
determine the qualifications that attendants were required to meet 
 
22 Previous OIG work with PCS claims data found substantial variability in the amounts 
paid for individual claims.  This variability is due to differences in State payment rates, 
State billing policies, and beneficiaries differing levels of need.  Stratifying the sample 
helped ensure the precision of our estimate of inappropriate payments. 
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I N T R O D U C T I O N  
during the period covered by our review.  See Appendix B for details on 
the attendant qualifications that States had established for their 
programs.   
We also requested that each selected State provide copies of its policies 
and/or regulations that require documentation of attendant 
qualifications to be maintained.  Eight States required documentation of 
attendant qualifications to be maintained; two States did not.  Some of 
the eight States required specific documents to be maintained, such as 
training certificates or background check logs, while other States did 
not specify the required documents. 
Collection and Analysis of Documentation To Support Attendant 
Qualifications   
For each sampled claim, we asked State Medicaid agency officials to 
identify the agency or individual we should contact to request 
documentation to support PCS attendants qualifications.  Agencies and 
individuals that we contacted are hereinafter referred to as 
respondents.   
We made at least three attempts to contact each of the respondents.  
The first and second attempts were made through regular mail or by 
FAX; the third and final attempt was made through certified U.S. mail 
or Federal Express.  We established contact with respondents for 424 of 
the sampled claims, a response rate of 94 percent.  We were unable to 
establish contact with respondents for the remaining 26 claims; 
therefore, they are considered nonrespondents.  A nonresponse analysis 
found no evidence of bias based on stratum or State location.   
For each sampled claim, we requested documentation to support that 
the attendant(s) who provided the PCS met all attendant qualifications.  
In response to our request, respondents provided copies of a variety of 
documents, including:  
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I N T R O D U C T I O N  
  results of background or criminal history checks, including checks of 
State abuse registries and/or OIGs list of Excluded Individuals and 
Entities;23  
  training certificates or logs; 
  drivers licenses or birth certificates;  
  immunization or other health records; and 
  high school diplomas, GED certificates, or other verification of 
education and/or literacy. 
Because State documentation requirements varied, we accepted a wide 
variety of documentation to support that attendants were qualified to 
provide Medicaid PCS.  Because we did not seek to determine whether 
the documentation provided would have been deemed sufficient by a 
particular State, we accepted documentation supporting any component 
of a qualification as complete documentation for meeting that 
qualification.  For example, some programs require that attendants 
complete a minimum number of course hours focused on specific content 
as part of their training qualification.  If we received documentation 
supporting the required course hours but the documentation did not 
specify the course content, we considered the attendant to have met the 
training qualification.  As a result, our estimates are conservative.  See 
Appendix C for details on the documentation we received and accepted 
for different qualification types.   
Inappropriate Claims for Medicaid PCS 
We reviewed the documentation of attendant qualifications submitted 
for all claims.  For claims from the eight States that required 
documentation of attendant qualifications to be maintained, we 
determined that a claim was inappropriate if we established contact 
with the respondent but received no documentation to support that the 
attendant met one or more of the qualifications.  The entire claim was 
deemed inappropriate if any qualification for any attendant involved in 
it was undocumented.  For claims from the two States without 
documentation requirements, we considered all claims appropriate 
because the respondent was not required to maintain documentation of 
attendant qualifications.     
 
23 The Social Security Act gives OIG the authority to exclude individuals and entities 
who have engaged in fraud or abuse from participation in Medicare, Medicaid, and other 
Federal health care programs.  OIG maintains a list of currently excluded individuals and 
entities, available online at http://oig.hhs.gov/fraud/exclusions/exclusions_list.asp. 
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I N T R O D U C T I O N  
Some respondents replied to our request for documentation by stating 
that they had no record of serving the specified beneficiaries.  We 
considered the claim inappropriate if respondents indicated that they 
had no record of the service or beneficiary. 
We analyzed the characteristics of the inappropriate claims, including 
the specific qualifications that were undocumented and the types of 
programs the claims were paid through, but did not identify any 
patterns in these characteristics. 
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspections approved by the Council of the Inspectors General on 
Integrity and Efficiency. 
 
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 F I N D I N G S  
Attendant qualifications were undocumented for  Eighteen percent of paid Medicaid 
18 percent of Medicaid PCS claims, resulting in  PCS claims (6.5 million) in our 
universe were inappropriate because 
$724 million in inappropriate payments 
attendants qualifications were 
undocumented.  From 
September 1, 2006, through August 31, 2007, Medicaid paid 
approximately $724 million for these claims.24  For 43 percent of these 
claims, we received some documentation regarding the attendants
usually identifying informationbut received no documentation to 
support that they met any of the States qualifications.  For the 
remaining 57 percent of these claims, we received documentation to 
support that attendants met some, but not all, of the qualifications.  The 
payments for both groups of claims were inappropriate because of the 
lack of documentation for one or more attendant qualifications.  Two of 
the selected States did not have documentation requirements, so we 
considered all claims in those States to be appropriate. 
Background checks were the most frequently undocumented qualification 
Respondents failed to provide documentation of attendant background 
checks for 5 percent of the claims (1.7 million).  In the absence of 
documentation to support that a background check was conducted, we 
could not determine whether an attendants background should have 
disqualified him/her from providing Medicaid PCS.  Similarly, 
respondents did not provide documentation that State abuse and 
neglect registries had been checked.  Appearing on those registries 
would usually disqualify attendants from providing services.   
Many respondents also failed to provide documentation to support that 
attendants met age (1.2 million claims or 3.5 percent) or education 
(451,480 claims or 1.3 percent) qualifications.  Table 3 lists the types of 
qualifications for which respondents did not provide documentation. 
 
24 The percentages, numbers, and dollar amounts associated with inappropriately paid 
claims are statistical projections to the universe of claims based on the sample claims 
reviewed. 
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FFF III NNN DDD III NNN GGG SSS    
 
Table 3:  Undocumented Attendant Qualifications  
Qualification Lacking  Percentage of 
Total Claims
Documentation  Claims 
Background  1,779,852  5.0% 
Age   1,237,304  3.5% 
Literacy/education  451,480  1.3% 
Other  357,368  1.0% 
Health   174,190  0.5% 
Training  7,007  0.02% 
Source:  OIG analysis of Medicaid claims data, 2009. 
 
Respondents failed to provide documentation for multiple qualifications 
for nearly 1 percent of paid PCS claims (303,315).  For example, one 
program in our sample required attendants to complete initial and 
continuing training, have a high school diploma or GED, and pass a 
statewide criminal background check.  However, for one of the claims 
we sampled from this program, we only received documentation of the 
attendants initial and continuing training.  We received no 
documentation of the attendants education or background check. 
 
For 2 percent of Medicaid PCS claims,  Respondents for 2 percent of 
respondents had no record of serving   paid Medicaid PCS claims in our 
universe (552,578) reported they 
the beneficiaries 
had no record of ever providing 
services to the beneficiaries named in the claims data.  From 
September 1, 2006, through August 31, 2007, Medicaid paid 
approximately $63 million for these inappropriate claims.25     
 
25 The amount inappropriately paid is a statistical projection to the universe of claims 
based on the sample claims reviewed.  The 95-percent confidence interval for this point 
estimate is $11,450,290$113,789,851.  
  OEI-07-08-00430  INAPPROPRIATE CLAIMS FOR MEDICAID PERSONAL CARE SERVICES  11    
   
 R E C O M M E N D A T I O N S  
 
 
Medicaid programs inappropriately paid $724 million for 18 percent of 
PCS claims in our universe because attendants qualifications were 
undocumented.  Medicaid inappropriately paid another 2 percent of 
claims in our universe because the respondents had no record of 
providing services to the beneficiaries.  Prior OIG reports related to 
Medicaid PCS also identified inappropriately paid claims and/or claims 
vulnerable to payment errors.       
Medicaid expenditures for PCS increased 20 percent between 2004 and 
2006.  Furthermore, CBO estimates a $2.6 billion increase in Federal 
expenditures for Medicaid PCS by 2015.  Given the continuing increase 
in PCS utilization and expenditures, the integrity of the providers of 
and payments for these services is vital to ensuring the health and 
welfare of Medicaid beneficiaries.     
In light of these findings, CMS should: 
Ensure that Medicaid claims for PCS provided by attendants with 
undocumented qualifications are not paid 
CMS could work with States to ensure that: 
  State Medicaid directors and staff are aware of the findings of this 
and previous reports on PCS so they can target their program 
integrity efforts, 
  agencies and attendants providing PCS are aware of attendant 
qualifications and documentation requirements, and 
  State Medicaid programs have a method to verify that attendant 
qualifications are met. 
Take action regarding the inappropriate claims identified in our review 
We will forward information regarding the inappropriate claims we 
identified to CMS in a separate memorandum.  CMS may want to work 
with States to recover the Medicaid payments for PCS provided by 
unqualified attendants and/or attendants for whom we received no 
documentation to support that they met qualifications in States that 
require such documentation.  CMS may want to pay particular attention 
to the inappropriate claims for which respondents said they had no 
record of serving the beneficiaries named in the claims data. 
  OEI-07-08-00430  INAPPROPRIATE CLAIMS FOR MEDICAID PERSONAL CARE SERVICES  12    
   
F I N D I N G S  
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
CMS concurred with both recommendations.  In response to the first, 
CMS described plans to work with States to ensure that Medicaid 
claims for PCS provided by attendants who do not meet States 
qualifications are not paid.  CMS indicated it will work through the 
State plan amendment and waiver review process, and other 
educational and communication opportunities, to address this 
recommendation.  Based on previous OIG reports, CMS has included 
new questions related to PCS in the Comprehensive State Program 
Integrity Reviews.  CMS noted that it continues to work with State 
Medicaid programs to determine whether there are ways that PCS 
attendant qualifications could be addressed, such as collaborative 
projects or claims audits.  CMS also indicated it will evaluate whether 
the development of best practice guidelines would assist State Medicaid 
programs in establishing documentation requirements for personal care 
attendants.  In response to the second recommendation, CMS stated it 
will review the information regarding the inappropriate claims we 
identified, and take appropriate action based on that review.  For the 
full text of CMSs comments, see Appendix D.  We made technical 
corrections to the report based on CMSs comments. 
  OEI-07-08-00430  INAPPROPRIATE CLAIMS FOR MEDICAID PERSONAL CARE SERVICES  13    
   
A P P E N D I X   ~   A  
 AA PP PP EE NN DD II XX    ~~    AC   

Table A-1:  Point Estimates and Confidence Intervals 
Sample  95-Percent Confidence 
Statistic Description  Point Estimate
Size Interval
Claims With Undocumented Attendant Qualifications 
Percentage of inappropriately paid claims  424  18.4  14.223.4 
Number of inappropriately paid claims  424  6,520,805  5,030,1978,339,223 
Total payments for inappropriately paid claims  424  $724,066,379  $565,824,009$882,308,749 
Among inappropriately paid claims, percentage 
with no documentation of any attendant  91  43.2  30.357.0 
qualifications 
Among inappropriately paid claims, percentage 
with documentation for some, but not all,  91  56.8  43.070.0 
attendant qualifications 
Percentage of claims with undocumented 
424  5.0  3.08.3 
background check qualification 
Number of claims with undocumented 
424  1,779,852  1,060,8912,946,507 
background check qualification 
Percentage of claims with undocumented age 
424  3.5  1.86.6 
qualification 
Number of claims with undocumented age 
424  1,237,304  639,9932,356,329 
qualification 
Percentage of claims with undocumented 
424  1.3  0.43.8 
education qualification 
Number of claims with undocumented  
424  451,480  148,9731,346,046 
education qualification 
continued on next page 
 
   
  OEI-07-08-00430  INAPPROPRIATE CLAIMS FOR MEDICAID PERSONAL CARE SERVICES  14    
   
A P P E N D I X   A  
Table A-1:  Point Estimates and Confidence Intervals (Continued) 
Sample  95-Percent Confidence 
Statistic Description  Point Estimate
Size Interval
Claims With Undocumented Attendant Qualifications (continued) 
Percentage of claims with other undocumented 
424  1.0  0.33.0 
qualifications 
Number of claims with other undocumented  
424  357,368  116,2001,084,493 
qualifications 
Percentage of claims with undocumented health 
424  0.5  0.073.4 
qualification 
Number of claims with undocumented health 
424  174,190  24,2811,219,412.3 
qualification 
Percentage of claims with undocumented training 
424  0.02  0.0020.1 
qualification 
Number of claims with undocumented training 
424  7,007  98249,961 
qualification 
Percentage of claims that had more than one 
424  0.9  0.23.0 
undocumented qualification 
Number of claims that had more than one 
424  303,315  85,6631,058,277 
undocumented qualification 
Claims With Undocumented Services 
Percentage of claims with no documentation to 
424  1.5  0.64.0 
support that services were provided 
Number of claims with no documentation to support 
424  552,578  212,4591,416,424 
that services were provided 
Total payments for claims with no documentation to 
424  $62,620,070  $11,450,290$113,789,851 
support that services were provided 
Source:  Office of Inspector General analysis of Medicaid claims data and attendant qualification documentation, 2010. 
 
  OEI-07-08-00430  INAPPROPRIATE CLAIMS FOR MEDICAID PERSONAL CARE SERVICES  15    
   
 A P P E N D I X   ~   B  
Table B-1:  Types of Attendant Qualifications and Documentation Requirements Established by States 
In the table below, the  symbol represents an attendant qualification 
with a corresponding documentation requirement.  The  symbol 
represents an attendant qualification with no corresponding 
documentation requirement.   
Training Requirement 
State  Program  Age  Education  Health  Background  Other  Total 
  Hours  Content 
 Program 1                   4 
 Program 2                      1 
 CA 
 Program 3                      1 
 Program 4                      1 
 Program 1                   3 
               5 
 Program 2 
               5 
               5 
 Program 3 
               5 
               5 
 Program 4 
                4 
 FL                 5 
 Program 5 
               5 
               5 
 Program 6 
               5 
 Program 7                   4 
 Program 8                      1 
               5 
 Program 9 
               5 
 Program 1                   4 
 Program 2                   3 
 GA 
 Program 3                    3 
 Program 4                    3 
continued on next page 
  OEI-07-08-00430  INAPPROPRIATE CLAIMS FOR MEDICAID PERSONAL CARE SERVICES  16    
   
A P P E N D I X   ~   B  
Table B-1:  Types of Attendant Qualifications Established by States (continued) 
Training Requirement 
State  Program  Age  Education  Health  Background  Other  Total 
  Hours  Content 
                  3 
 Program 1 
                   2 
                  3 
 Program 2 
                   2 
                  3 
 Program 3 
                   2 
  IA 
                  3 
 Program 4 
                   2 
                  3 
 Program 5 
                   2 
                  3 
 Program 6 
                   2 
                4 
 Program 1 
                4 
                4 
 Program 2 
                 4 
                 3 
 Program 3 
  IL                   4 
                  2 
 Program 4 
                    1 
 Program 5                 3 
                  2 
 Program 6 
                    1 
 NE   Program 1                    3 
continued on next page 
 
  OEI-07-08-00430  INAPPROPRIATE CLAIMS FOR MEDICAID PERSONAL CARE SERVICES  17    
   
A P P E N D I X   ~   B  
Table B-1:  Types of Attendant Qualifications Established by States (continued) 
Training Requirement 
State  Program  Age  Education  Health  Background  Other  Total 
  Hours  Content 
              5 
 Program 1 
 NY                   4 
 Program 2                5 
 Program 1                    3 
                   2 
 Program 2 
                  3 
 Program 3                 3 
                4 
  OH   Program 4 
                4 
                   2 
 Program 5 
                  3 
                4 
 Program 6 
                4 
 Program 1                6 
 Program 2                6 
 Program 3                5 
 TN 
 Program 4                 4 
 Program 5                 4 
 Program 6                6 
 Program 1                    2 
  WV 
 Program 2                     2 
     Total  31  42  49  26  33  56  26   263 
Source:  Office of Inspector General analysis of State qualification information, 2010. 
  OEI-07-08-00430  INAPPROPRIATE CLAIMS FOR MEDICAID PERSONAL CARE SERVICES  18    
   
 A P P E N D I X   ~   C  
Details of Documentation Received and Office of Inspector General Analysis 
Criteria To Substantiate Attendant Qualifications 
To produce a conservative estimate of error, the Office of Inspector 
General (OIG) accepted a wide variety of documentation as proof that 
attendants were qualified.  Documentation submitted varied among 
States, programs, and respondents.  In general, we required 
documentation to indicate the attendants name and the date of the 
document.  The types of documents we received, and any specific 
information we required to consider the attendant qualified, are 
described below. 
Training.  The documentation we received regarding training 
qualifications included: 
  certificates for specific training courses, 
  in-service training logs, 
  cardiopulmonary resuscitation and first aid certification cards,  
  training curriculums and syllabuses, and 
  completed examinations.   
In addition to the attendants name and the date of the training, we 
required that the documents indicate that the attendant had completed 
either at least some of the required hours of training, or at least some of 
the required content.   
Background checks.  The documentation we received regarding 
background check qualifications included: 
  the results of background checks done by State and county 
agencies, the Federal Bureau of Investigation, and private 
agencies; 
  personal and professional references, including letters of 
reference, reference forms, and employment applications 
requiring contact information for references; 
  employment applications including employment history; 
  results of checks of various State registries, including child and 
adult abuse, nurse aide, and sex offender registries; 
  credit reports; 
  checks of OIGs List of Excluded Individuals and Entities; and 
  OEI-07-08-00430  INAPPROPRIATE CLAIMS FOR MEDICAID PERSONAL CARE SERVICES  19    
   
A P P E N D I X   C  
  personal affidavits stating that the attendant had no criminal 
history. 
In a few cases in which employment history or professional references 
were required, the documentation noted that the attendant had never 
worked outside the home before and had no history or references.  
Additionally, for some programs in which a background check was 
required, the attendant was hired by the agency before the background 
check was completed.  We accepted the documentation explaining the 
circumstances in both of these situations as sufficient. 
For criminal background checks, we required that the document 
indicate the scope of the check (local, State, or Federal).  We did not 
require evidence that personal or professional references had been 
verified to consider the attendant qualified unless the qualification 
specified verification of the references; we only required that the 
reference information (usually the references name and contact 
information) be present.    
Age.  The documentation we received regarding age qualifications 
included: 
  drivers licenses,  
  birth certificates, and  
  voter registration cards.   
To consider an attendant qualified, age documentation had to be an 
official government document showing the attendants date of birth.  In 
some cases, when no other document was provided for the age 
qualification, we were able to verify the attendants age using 
documentation provided for other qualifications, such as motor vehicle 
records checks or background check documents. 
Health.  The documentation we received regarding health qualifications 
included: 
  tuberculosis tests and chest x-ray reports, 
  physical exams and health assessments, 
  drug screens, 
  laboratory tests to prove immunizations, 
  immunization records, and 
  letters or notes from physicians. 
  OEI-07-08-00430  INAPPROPRIATE CLAIMS FOR MEDICAID PERSONAL CARE SERVICES  20    
   
A P P E N D I X   C  
In some cases, the respondents explained that they required attendants 
to complete yearly health assessments and that they keep only the 
current year on file.  Therefore they were unable to provide us with the 
health assessment for the calendar year of the sampled claim.  As long 
as documentation of the current health assessment was provided, we 
considered these attendants to be qualified. 
Literacy or Education.  The documentation we received regarding 
education qualifications included: 
  high school diplomas, 
  General Educational Development certificates, and  
  literacy tests. 
Nine of the programs represented in our sample of claims required that 
attendants be able to read and write and communicate with the 
beneficiary and supervisors.  Often the documentation for the claims 
sampled from these programs was not specific to education or literacy.  
Lacking other materials, we accepted any other document that showed 
that the attendant was able to read and write, such as the attendants 
employment application, a written affidavit on behalf of the individual 
or agency, and any written documentation completed by the attendant.   
Other.  Some of the programs from which we sampled claims included 
qualifications that did not fit in any other category.  These included: 
  requiring attendants to have a valid drivers license and current 
automobile insurance, or to pass a motor vehicle records check if 
their duties included transporting the beneficiary;  
  requiring the attendant to pass a periodic performance evaluation; 
and 
  requiring the attendant to complete employment status 
documentation (such as employment eligibility verification forms) 
or an employment agreement (such as a contract outlining duties 
and expectations of the attendant and beneficiary). 
The documentation we received regarding other qualifications included 
copies of the specified licenses, insurance cards, record checks, 
performance evaluations, and employment forms. 
  OEI-07-08-00430  INAPPROPRIATE CLAIMS FOR MEDICAID PERSONAL CARE SERVICES  21  A  P  PEN  D  x  D 
Agency Comments 
(  E 
r'.~"'''''''C''' 
DEPARTMENT OFfmALlH " HUMAN SERVICES  Centers for MedIcare & Medicaid Services
10,'"'''' 	
Admillistratar 
washlngton, DC 20201 
DATE:  OCT  2 0 20X! 
TO: 	 Daniel R. Levinson 

Inspector General 

FROM: 	 Donald Berwick, M.D. 

Administrator 

SUB.JECT: 	 Office oflnspeclor Genel1l1 (OIG) Draft Report: "Inappropriate Claims for Medicaid 
Personal Cure Services" (OEI-07-0S.00430) 
The Centers for Medicare & Medicaid Services (CMS) appreciate the opportunity to comment on this 
draft repor(.  In this draft report, the OIG determines whether Medicaid claims for personal care 
services (PCS) were inappropriate because--(I) attendants' qualifications wcre undocumented and 
therefore it was not known whether attendants were qualified; or (2) providers had no records of 
serving beneficiaries. 
PCS are furnished to beneficiaries in their home and other community-based settings. The provision 
ofPCS by PCS attendants allows elders and persons with disabilities to remain in their own homes 
and communities. It is estimated that at least 36 States olTer PCS as an optional service in their State 
Medicaid plans.  Many States also offer pes in numerous waiver programs. PCS can comprise 
myriad services such as assistance with eating, bathing, dressing, light housework, meal preparation, 
money management, supervision and cueing. Many States have set requirements for attendant 
quaIii1cations in order to ensure the health, welfare and safety of beneficiaries and to meet Medicaid 
requirements at 42 C.F.R  440. I 67(A)(2) that PCS are furnished "by An individual who is qualitled 
to provide such services...... These qualifications. as defined by States, range from age and 
edueation requirements. to background checks. to training requirements.  To ensure program 
integrity, States are also required to pay only for .PCS actually rendered to bencficiaries. 
The 010 rep0l1 notes that not all States maintain accurate documentation of aHendant qualifications 
so Stales do not know whether all attendants are meeting their qualification requirements. The report 
also notes that not all States or providers have records of providing services to beneficiaries for 
whom there were Medicaid claims.  We acknowledge and appreciate the OIG's efforts in undertaking 
this study and believe the findings will be helpful as we implement the OIO's recommendations. 
OIG Recommendations 
The 010 recommends that CMS take the following steps: 
]. 	Ensure that Medicaid claims for pes provided by attendants with undocumented 
qualifications are not paid. 
CMS could accomplish this by working with States to ensure that
OEI070800430  INAPPROPRIATE CLAIMS FOR MEDICAID PERSONAL CARE SERVICES  22    
   
A P P E N D I X   D  
Agency Comments (continued) 
  OEI-07-08-00430  INAPPROPRIATE CLAIMS FOR MEDICAID PERSONAL CARE SERVICES  23    
   
A P P E N D I X   ~   C  
 A C K N O W L E D G M E N T S  
 
This report was prepared under the direction of Brian T. Pattison, 
Regional Inspector General for Evaluation and Inspections in the 
Kansas City regional office, and Deborah K. Walden, Deputy Regional 
Inspector General.   
Michala Walker served as the lead analyst for this study.  
Other principal Office of Evaluation and Inspections staff from the 
Kansas City regional office who contributed to the report include 
Michael Barrett and Megan Buck Bhakta; central office staff who 
contributed include Robert Gibbons and Kevin Manley.  
 
 
  OEI-07-08-00430  INAPPROPRIATE CLAIMS FOR MEDICAID PERSONAL CARE SERVICES  24   
 
Office of Inspector General 
http://oig.hhs.gov 
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department of Health and Human Services 
(HHS) programs, as well as the health and welfare of beneficiaries served by those 
programs.  This statutory mission is carried out through a nationwide network of audits, 
investigations, and inspections conducted by the following operating components: 
Office of Audit Services 
The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting 
audits with its own audit resources or by overseeing audit work done by others.  Audits 
examine the performance of HHS programs and/or its grantees and contractors in carrying 
out their respective responsibilities and are intended to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and 
mismanagement and promote economy and efficiency throughout HHS. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud, waste, or abuse and promoting 
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations 
of fraud and misconduct related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI utilizes its resources 
by actively coordinating with the Department of Justice and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to criminal 
convictions, administrative sanctions, and/or civil monetary penalties. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to 
OIG, rendering advice and opinions on HHS programs and operations and providing all 
legal support for OIGs internal operations.  OCIG represents OIG in all civil and 
administrative fraud and abuse cases involving HHS programs, including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program guidance, publishes fraud alerts, and provides other 
guidance to the health care industry concerning the anti-kickback statute and other OIG 
enforcement authorities.