The FBI called it the “largest health care fraud takedown in D.C. history.” On Feb. 20, U.S. Attorney Ron Machen announced that federal investigators had issued 25 arrest warrants for employees of 13 home health care agencies in the District that were conducting fraudulent schemes under the Medicaid program like billing for services to beneficiaries who were incarcerated or dead and paying beneficiaries to sign falsified time sheets so the agencies could collect fees without conducting services.
“This investigation has revealed that Medicaid fraud in the District of Columbia is at epidemic levels,” Machen said at the time. “This fraud diverts precious taxpayer dollars, drives up the cost of health care and jeopardizes the strength of a program that serves the most vulnerable members of our society. However, as today’s arrests, searches, and seizures demonstrate, we are aggressively fighting back to protect the U.S. taxpayer and the integrity of our federal health care programs.”
The good guys, it seemed, had won. But there may have been some unforeseen losers in the aftermath: D.C. residents who depend on home health-care services. According to the Legal Counsel for the Elderly, a legal services program under AARP, complaints to the organization regarding home health services under Medicaid in D.C. have increased by more than 500 percent since the raid.
Rhonda Bruton says that after the raid, her elderly mother’s services were suddenly reduced. Her mother, Delores Flood, suffers from a host of ailments—-among them: diabetes, hypertension, kidney failure, epilepsy, and partial paralysis from a stroke nearly two decades ago—-and had been receiving around-the-clock care at her Congress Heights home through Medicaid. But suddenly the night service, from 11 p.m. to 7 a.m., stopped. Bruton says she was told that the District had stopped contributing its portion of the Medicaid payments starting in March.
“I had to stay at my mom’s house and take care of her overnight, meaning I had to leave my family to stay with her,” Bruton says. “I slept on a blowup mattress, because there was no one coming at night.” That lasted for a few weeks, Bruton says; then, without explanation, the night service resumed.
According to Tina Nelson, an attorney with the Legal Counsel, Flood is one of many patients whose services were affected by the raid. After the city suspended payments to 13 home health care agencies, she says, some health aides stopped working. “When D.C. came in with the FBI raid, it left the beneficiaries in flux,” Nelson says. “They were no longer allowed to service these clients. All of these clients had to be transferred to the agencies that were not affected by the shutdown. That created a lot of problems. A lot of the agencies that still existed didn’t have the capacity to pick up these beneficiaries that were being transferred.”
Wayne Turnage, director of the D.C. Department of Health Care Finance, says that’s not true, and that the health-care vendors the city contracts with can take on 60 percent more capacity than they currently serve. Of the 13 suspended agencies, he says, seven have returned to operations, and the city added six vendors to replace those lost. “If you are an eligible beneficiary, you are not denied care,” he maintains. “There is nothing in place that would prevent any beneficiary from getting care.”
In the more than seven months since the raid, the Legal Counsel has received opened 43 cases regarding complaints about home health services through Medicaid. In the same time period last year, there were just seven cases. And the pace of complaints doesn’t appear to be slowing down significantly, with seven new ones in the past month and a half. As Turnage points out, that’s not a huge sample size (compared with the more than 3,000 total program participants); Nelson counters, “Those are just the clients that are finding us. What about the clients that are not making their way to our office?”
Turnage shares the above chart and argues that the decline in the number of program beneficiaries is proof that many of those previously enrolled were fraudulent or ineligible. “This clearly means that many of the beneficiaries who were served by the agencies that faced payment suspensions left the program following the imposition of the sanctions and, thus far, have elected not to seek personal care services with any eligible provider,” he says in an email. “It almost goes without saying that many of these cases were likely fraudulent.”
Nelson and her colleagues counter that the Department of Health Care Finance has been overly aggressive in trying to shed program participants. “This is all about the numbers, about dollar signs and Health Care Finance people wanting to tag beneficiaries with fraud,” she says.
Turnage says his office has made every effort to reach out to prior beneficiaries by phone or mail and check to see if they needed services they were not receiving, and that no one requiring services has been left out. He also says he had no choice but to suspend all the agencies accused of fraud. “The notion that we suspended excessively ignores the legal requirement that we have to suspend payment if there’s a credible allegation of fraud,” he says.
Chart from the Department of Health Care Finance