9/19/2017. Financial Oversight. 9/19/2017 Minnesota Department of Human Services mn.gov/dhs 1. What are HCBS services?

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1 Office of the Legislative Auditor s Report: HCBS Audit Financial Oversight 9/19/2017 Minnesota Department of Human Services mn.gov/dhs 1 What are HCBS services? 1

2 Home Care Services Home Health Agency Services Home Care Therapies (PT, OT, SLP, RT) Home Health Aide (HHA) Skilled Nurse Visit (SNV) Medical Equipment Personal Care Assistance (PCA) Home Care Nursing (HCN) Home and Community Based Service (HCBS) Waivers HCBS Waivers Brain Injury (BI) Community Alternative Care (CAC) Community Access for Disability Inclusion (CADI) Developmental Disabilities (DD) Elderly Waiver (EW) Examples of Services Independent Living Skills Supported Employment Foster Care Day Training & Habilitation Respite Extended PCA Consumer Directed Community Supports (CDCS) 2

3 Recommendations 3 main recommendations The legislature should increase its regulation over direct care workers who provide HCBS in residential settings. The legislature should require the Department of Human Services to regularly collect data on direct care staffing in HCBS settings. The legislature & DHS should adopt a common set of financial reporting requirements and menu of services. 3

4 Where are we today? Over the past few decades, Minnesota has shifted from the highest per capita capacity in institutional services to 94% of Minnesotans with disabilities receive HCBS services in the community. This means Minnesota is supporting many people with complex needs through the HCBS waivers, instead of through institutional care. Older adults and people with disabilities are supported by thousands of providers in the community in a variety of ways to meet their individual needs. This shift has resulted in a person centered system that relies on a flexible service menu, complex rate system, and provider standards to assure the right protections for people. The Olmstead Plan ensures people with disabilities are living, learning, working, and enjoying life in the most integrated setting, in a person centered way. Workforce Challenges Person centered services, as well as workforce challenges, require thinking about different ways to support people How to most effectively use human assistance to support people Using technology effectively Create career ladders and other incentives for people to go into the HCBS field Collect data to better understand workforce challenges and ways to mitigate the challenges 4

5 Other Challenges People have choices about services, providers, and the way services are delivered; however, there are limits to choices when using public HCBS funds. HCBS setting requirements provide direction on the type of setting that can receive HCBS funds. Reform efforts take time to achieve results and we don t always have all of the necessary data for effective implementation. Evaluate individual service outcomes Which investments lead to the best outcomes for people Managing System Growth Corporate foster care moratorium to limit the growth of an expensive model of residential services Disability waiver rate system authorized to establish statewide rates for similar services 245D licensure authorized to establish statewide standards across waiver services Common menu of services across the disability waivers to assure people have access to the services they need Housing Support Reform to allow for more people to live in the community 5

6 System Changes In Process New employment services that promote community based, competitive employment (authorized by 2017 legislature; submitted to CMS by 10/1/2017) Enhanced supports for people living in their own home (authorized by legislature and approved by CMS in 2017; fall 2017 implementation) New service for people living in settings that are partially controlled by a service provider (in development with stakeholders) Training to build provider capacity in the new models of service Development of plain language materials for people receiving services and their families to understand the changes in the way services are delivered System edits are in place to prevent billing for more than 24 hours/day Future Development in Alignment with Recommendations Study on the feasibility of consolidation of four disability waivers (due January 2019) Requirement for HCBS providers to submit cost data to DHS every five years Study on individual budgeting methodology for disability waiver recipients (due December 2018) DHS convened an internal workgroup to work on system edits related to single day billing Electronic Service Document Delivery System workgroup recommendations (due January, 2018) 6

7 Legislative action needed HCBS Documentation (SF 1291, Article 3, Sec. 30) Workforce Data collection (SF 781, Article 1, Sec. 13) PCA Fraud Carolyn Ham Inspector General 7

8 OIG: Financial Fraud and Abuse Investigations Division (FFAID) The Financial Fraud and Abuse Investigations Division (FFAID) is responsible for investigating activities in DHS public programs. It investigates: Billing violations by providers who are reimbursed by Medical Assistance and the Child Care Assistance Program Recipients of or applicants for public benefits when there is suspicion or questionable eligibility. OIG: FFAID Staff OIG/FFAID oversees provider billing for the $12 billion Medicaid industry in Minnesota, which consists of 100 different provider types (Personal Care Services, Pharmacy, Transportation etc.), and over 240,000 enrolled Medicaid providers. Currently there are 16 investigators in FFAID that investigate Medicaid providers 2017 Legislation provided funding for an additional 10 staff 8

9 2016 Completed Medicaid Investigations by Provider Type HOSPITAL REHABILITATION AGENCY HOME AND COMMUNITY SERVICE PHYSICIAN BILL ENTITY FOR MENTAL HEALTH PERSONAL CARE PROVDIDER FAMILY PLANNING AGENCY PHARMACY MEDICAL TRANSPORTATION OTHER Personal Care Provider Common Fraud Schemes Falsification of the need for PCA services during the recipient s assessment process Personal Care Attendant (PCA) and Recipient split the PCA s wage without services being provided Provider agency steals the identity of a recipient, PCA, or qualified professional in order to submit claims to DHS A PCA submits a claim for a recipient when one or the other are in an inpatient facility Claims are submitted for personal care services while either the recipient or the PCA are in jail or out of state (country) Providers overbill services PCAs submit timesheets for personal services when they are clocked in at another job 9

10 Personal Care Assistance Fraud, Abuse or Error 189 PCA Fraud, Abuse or Error cases completed in 2016 $1.4 Million in overpayments 42% of cases investigated resulted in termination, suspension, conviction or stipulated provider agreement 172 cases completed on other provider types in % of cases investigated resulted in termination, suspension, conviction or stipulated provider agreement OIG Concerns HCBS Providers provide a wide range of services to recipients. Not all HCBS are susceptible to fraud and abuse. Services provided by direct care staff in a recipient s home, where there is no direct supervision, are susceptible to fraud and abuse and therefore warrant additional oversight. Acts of abuse, neglect and financial exploitation against vulnerable adults are more often than not committed by individuals known to a victim, such as family members and friends. 10

11 OIG Legislative action needed Legislation (SF1291) on Waiver services documentation Documentation requirements in Waivered services were proposed in 2017, but did not pass. Minnesota is currently not in compliance with Federal law by failing to have documentation requirements in Waivered services Legislation (SF1292, as introduced) that would limit the choice option for recipients who colluded or were coerced to participate in fraudulent activity Questions? 11