Health Law Blog - Healthcare Legal Issues

Posts Tagged ‘Personal Care Agencies’

Personal Care Agency Fraud – Business Structure Can Impact Compliance Risk

Tuesday, June 27th, 2017

Personal Care Agency Structure Can Increase Risk and Government Scrutiny

Personal Care Agency FraudThe OIG recently released a review of Medicaid Fraud Control Unit activities which identified personal care agencies as accounting for nearly one-third of fraud prosecutions.  Previous blogs identified a number of compliance risks that often ensnare agencies.  Risk can also be impacted by the structure and nature of the business that is conducted by the agency.  The business might be perfectly legal, but can still create additional risk.

An good example involves personal care agencies that focus on recruiting patients with extended families who already reside with the patient.  A personal care business plan that focuses on training extended family might be technically legal, but can certainly present risk that a reviewer will more closely scrutinize record-keeping, PCW training, and other requirements.  Closer scrutiny may result in overpayment requests and/or investigation.

The normal business plan for a personal care agency involves the hiring and training of personal care worker who are assigned to clients who retain the agency’s services.  Normally, a PCW and a client do not know each other and certainly are not sharing a residence with the client.  Some agencies might focus their business on recruitment of patients who live with extended family.  Simply by providing training to the existing family member, the agency is able to generate reimbursement.  The extended family member is able to earn a wage for the service that it performed.

Immediate family will normally not qualify to generate reimbursement as a personal care work.  More distant family might be able to generate reimbursement.  There may be nothing specific in the laws of the applicable state that prohibits this type of arrangement.  At the same time, there is nothing prohibiting a regulator from more closely scrutinizing regulatory requirements when presented with agencies that may be technically legal but could be viewed as being abusive at their core.

The main point here is that business structure and other factors might present additional levels of risk to an agency.  Business structure should be considered as a factor when conducting risk analysis.  Businesses that are operated in technical compliance could present higher degrees of risk than more traditional business structures.

Personal Care Service Providers and Wisconsin Medicaid

Thursday, February 6th, 2014

Personal Care Service Providers – Wisconsin Medical Assistance

Wisconsin Statute § 49.45(42)(d)3 describes the types of organizations that qualify to receive Medicaid reimbursement for “personal care services.”  Qualified entities include licensed home health agencies and other entities that are certified under section (2)(a)(11) to provide personal care services under section 49.46(2)(b)6j.  The DHS does not appear to have implemented regulations that specifically describe the criteria that “other entities” must meet in order to become qualified to receive reimbursement from Medicaid for the provision of personal care services.

The applicable provisions of section 49.45(2)(a)(11) do not contain specific criteria that “other entities” must meet but simply refers to the requirement that DHS promulgate rules establishing qualifications of providers.  The referenced statutory provision does not refer specifically to the requirements that “other entities” must meet in order to qualify to receive reimbursement for personal care services.

The requirements that must be met in order to become a licensed home health are more extensive than the personal care services entity.  However, becoming licensed as a home health agency will qualify you to provide and bill for personal care services directly.  It would also permit you to bill private pay patients for skilled nursing and other home health services and would provide the foundation for you to receive CMS certification as a home health agency.

John H. Fisher

Health Care Counsel
Ruder Ware, L.L.S.C.
500 First Street, Suite 8000
P.O. Box 8050
Wausau, WI 54402-8050

Tel 715.845.4336
Fax 715.845.2718

Ruder Ware is a member of Meritas Law Firms Worldwide

Search
Disclaimer
The Health Care Law Blog is made available by Ruder Ware for educational purposes and to provide a general understanding of some of the legal issues relating to the health care industry. This site does not provide specific legal advice and you should not use the information contained on this site to address your specific situation without consulting with legal counsel that is well versed in health care law and regulation. By using the Health Care Law Blog site you understand that there is no attorney client relationship between you and Ruder Ware or any individual attorney. Postings on this site do not represent the views of our clients. This site links to other information resources on the Internet; these sites are not endorsed or supported by Ruder Ware, and Ruder Ware does not vouch for the accuracy or reliability of any information provided therein. For further information regarding the articles on this blog, contact Ruder Ware through our primary website.