Department of Health and Human Services

OFFICE OF 

INSPECTOR GENERAL 

 

INAPPROPRIATE CLAIMS FOR 

MEDICAID PERSONAL CARE 

SERVICES 

 

Daniel R. Levinson 

Inspector General 

December 2010 

OEI-07-08-00430 
 

 

 EXECUTIVE SUMMARY 

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 beneficiary’s 

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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EXECUTIVE SUMMARY 

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 

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EXECUTIVE SUMMARY 

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 CMS’s comments. 
 TABLE OF CONTENTS 

EXECUTIVE SUMMARY .....................................i

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 

FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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 

RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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 

ACKNOWLEDGMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
 

 

 INTRODUCTION 

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 beneficiary’s 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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INTRODUCTION 

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. 

2 

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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INTRODUCTION 

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). 

Background check 

Attendant must pass a State or national criminal background check; attendant must provide 

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. 

Health Attendant must be free of infectious or contagious disease; attendant must pass a physical exam 

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. 

Employment status: Attendant must complete immigration forms and employment agreement. 

Other 

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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INTRODUCTION 

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

4 

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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INTRODUCTION 

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 State’s 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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INTRODUCTION 

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 

Stratum Payment Amounts Claims in 

Universe

Claims in 

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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INTRODUCTION 

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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INTRODUCTION 

 results of background or criminal history checks, including checks of 

State abuse registries and/or OIG’s list of Excluded Individuals and 

Entities;23 

 training certificates or logs; 

 driver’s 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. 

8 

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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INTRODUCTION 

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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Attendant qualifications were undocumented for 

18 percent of Medicaid PCS claims, resulting in 

$724 million in inappropriate payments 

 FINDINGS 

Eighteen percent of paid Medicaid 

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.24 For 43 percent of these 

claims, we received some documentation regarding the attendants—

usually identifying information—but 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 attendant’s 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. 

10 

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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FINDINGS 

Table 3: Undocumented Attendant Qualifications 

Qualification Lacking 

Documentation Total Claims Percentage of 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 

attendant’s initial and continuing training. We received no 

documentation of the attendant’s education or background check. 

Respondents for 2 percent of 

paid Medicaid PCS claims in our 

universe (552,578) reported 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.25 

For 2 percent of Medicaid PCS claims, 

respondents had no record of serving 

the beneficiaries 

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. 

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 RECOMMENDATIONS 

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. 

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FINDINGS 

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 CMS’s comments, see Appendix D. We made technical 

corrections to the report based on CMS’s comments. 

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APPENDIX ~ A A

14 

Table A-1: Point Estimates and Confidence Intervals 

Statistic Description Sample 

Size Point Estimate 95-Percent Confidence Interval

Claims With Undocumented Attendant Qualifications 

Percentage of inappropriately paid claims 424 18.4 14.2–23.4 

Number of inappropriately paid claims 424 6,520,805 5,030,197–8,339,223 

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 

qualifications 

91 43.2 30.3–57.0 

Among inappropriately paid claims, percentage 

with documentation for some, but not all, 

attendant qualifications 

91 56.8 43.0–70.0 

Percentage of claims with undocumented 

background check qualification 424 5.0 3.0–8.3 

Number of claims with undocumented 

background check qualification 424 1,779,852 1,060,891–2,946,507 

Percentage of claims with undocumented age 

qualification 424 3.5 1.8–6.6 

Number of claims with undocumented age 

qualification 424 1,237,304 639,993–2,356,329 

Percentage of claims with undocumented 

education qualification 424 1.3 0.4–3.8 

Number of claims with undocumented 

education qualification 424 451,480 148,973–1,346,046 

continued on next page 

 

 APPENDIX ~ A PPENDIX ~ C 

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APPENDIX A 

Table A-1: Point Estimates and Confidence Intervals (Continued) 

Statistic Description Sample 

Size Point Estimate 95-Percent Confidence Interval

Claims With Undocumented Attendant Qualifications (continued) 

Percentage of claims with other undocumented 

qualifications 424 1.0 0.3–3.0 

Number of claims with other undocumented 

qualifications 424 357,368 116,200–1,084,493 

Percentage of claims with undocumented health 

qualification 424 0.5 0.07–3.4 

Number of claims with undocumented health 

qualification 424 174,190 24,281–1,219,412.3 

Percentage of claims with undocumented training 

qualification 424 0.02 0.002–0.1 

Number of claims with undocumented training 

qualification 424 7,007 982–49,961 

Percentage of claims that had more than one 

undocumented qualification 424 0.9 0.2–3.0 

Number of claims that had more than one 

undocumented qualification 424 303,315 85,663–1,058,277 

Claims With Undocumented Services 

Percentage of claims with no documentation to 

support that services were provided 424 1.5 0.6–4.0 

Number of claims with no documentation to support 

that services were provided 424 552,578 212,459–1,416,424 

Total payments for claims with no documentation to 

support that services were provided 424 $62,620,070 $11,450,290–$113,789,851 

Source: Office of Inspector General analysis of Medicaid claims data and attendant qualification documentation, 2010. 

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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. 

Program Training Requirement State 

Hours Content 

Age Education Health Background Other Total 

 Program 1 ○ ○ ○ ○ 4 

 Program 2 ○ 1 

 Program 3 ○ 1 

 CA 

 Program 4 ○ 1 

 Program 1 ● ● ● ● 3 

● ● ● ● ● ● 5 

 Program 2 

● ● ● ● ● ● 5 

● ● ● ● ● ● 5 

 Program 3 

● ● ● ● ● ● 5 

● ● ● ● ● ● 5 

 Program 4 

● ● ● ● ● 4 

● ● ● ● ● ● 5 

 Program 5 

● ● ● ● ● ● 5 

● ● ● ● ● ● 5 

 Program 6 

● ● ● ● ● ● 5 

 Program 7 ● ● ● ● 4 

 Program 8 ● 1 

● ● ● ● ● ● 5 

 FL 

 Program 9 

● ● ● ● ● 5 

 Program 1 ● ● ● ● 4 

 Program 2 ● ● ● ● 3 

 Program 3 ● ● ● 3 

 GA 

 Program 4 ● ● ● 3 

continued on next page 

 APPENDIX ~ B 

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APPENDIX ~ B 

Table B-1: Types of Attendant Qualifications Established by States (continued) 

Program Training Requirement State 

Hours Content 

Age Education Health Background Other Total 

 ○ ○ ○ 3 

 Program 1 

 ○ ○ 2 

 ○ ○ ○ 3 

 Program 2 

 ○ ○ 2 

 ○ ○ ○ 3 

 Program 3 

 ○ ○ 2 

 ○ ○ ○ 3 

 Program 4 

 ○ ○ 2 

 ○ ○ ○ 3 

 Program 5 

 ○ ○ 2 

 ○ ○ ○ 3 

 IA 

 Program 6 

 ○ ○ 2 

 ● ● ● ● 4 

 Program 1 

 ● ● ● ● 4 

 ● ● ● ● 4 

 Program 2 

 ● ● ● ● 4 

 ● ● ● 3 

 Program 3 

 ● ● ● ● 4 

● ● ● 2 

 Program 4 

 ● 1 

 Program 5 ● ● ● ● 3 

● ● ● 2 

 IL 

 Program 6 

 ● 1 

 NE Program 1 ● ● ● 3 

continued on next page 

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APPENDIX ~ B 

Table B-1: Types of Attendant Qualifications Established by States (continued) 

Program Training Requirement State 

Hours Content 

Age Education Health Background Other Total 

● ● ● ● ● ● 5 

 Program 1 

 NY ● ● ● ● 4 

 Program 2 ● ● ● ● ● ● 5 

 Program 1 ● ● ● 3 

 ● ● 2 

 Program 2 

 ● ● ● 3 

 Program 3 ● ● ● ● 3 

● ● ● ● ● 4 

 Program 4 

● ● ● ● ● 4 

 ● ● 2 

 Program 5 

 ● ● ● 3 

● ● ● ● ● 4 

 OH 

 Program 6 

● ● ● ● ● 4 

 Program 1 ● ● ● ● ● ● ● 6 

 Program 2 ● ● ● ● ● ● ● 6 

 Program 3 ● ● ● ● ● ● 5 

 Program 4 ● ● ● ● ● 4 

 Program 5 ● ● ● ● ● 4 

 TN 

 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. 

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 APPENDIX ~ 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 attendant’s 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 attendant’s 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 OIG’s List of Excluded Individuals and Entities; and 

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APPENDIX 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 reference’s name and contact 

information) be present. 

Age. The documentation we received regarding age qualifications 

included: 

 driver’s licenses, 

 birth certificates, and 

 voter registration cards. 

To consider an attendant qualified, age documentation had to be an 

official government document showing the attendant’s date of birth. In 

some cases, when no other document was provided for the age 

qualification, we were able to verify the attendant’s 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. 

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APPENDIX 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 attendant’s 

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 driver’s 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. 

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A P PEN D x D 

Agency Comments 

r'.~"'''''''C''' ( E 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 thatOEI·07·08·00430 INAPPROPRIATE CLAIMS FOR MEDICAID PERSONAL CARE SERVICES 22 
 

 

APPENDIX D 

Agency Comments (continued) 

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APPENDIX ~ C ACKNOWLEDGMENTS 

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. 
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 OIG’s 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.