3/20/2014. Time sheets should be signed:

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1 Time sheets should be signed: A. While your client is in the hospital B. On Monday or Friday C. After each date of service D. On the way to the office to turn them in The Investigators are: A. Fresh out of College B. All former and retired police officers C. All under 25 years old D. Incredibly busy with an average case load of 10 cases each 1

2 It is ok for the aide/attendant to have their clients: A. Buy them a cell phone B. Buy them a car C. Co sign for a loan D. Pay your bills Time sheets must include: A. Name B. Date C. Time spent providing the service D. All of the above Is it a good idea or bad idea to: A. Bring other people to your client s home B. Consume alcoholic beverages with a client in their home C. Breech your client s privacy and confidentiality of their personal information D. Reside with your client or have them reside with you if you are in the In Home Care program 2

3 MMAC, is otherwise known as Missouri Medicaid Audit and Compliance. Our mission is to enhance the integrity of the Missouri State Medicaid id program by preventing and detecting fraudulent, abusive and wasteful practices within the Medicaid program and recovering improperly expended Medicaid funds while promoting high quality patient care. MMAC investigators are responsible for conducting investigations into allegations of fraud, waste and abuse by providers and participants. Investigators conduct interviews with witnesses as well as those suspected of violating state regulation, state statute and federal regulations. In the event the investigation reveals a credible allegation of fraud by a provider, MMAC will forward the information to the Medicaid Fraud Control Unit (MFCU), or other prosecutorial entity for review. If the investigation reveals probable cause of fraud by a participant, MMAC will forward the information to local law enforcement for review. 7 Investigators plus 1 Supervisor All retired and former Police Officers with detective and patrol experience Well over 100 years of combined police experience 3

4 RSMo No health care provider shall knowingly make or cause to be made a false statement or false representation of a material fact in order to receive a health care payment. Health Care any service, assistance, care, product, device or thing provided pursuant to a medical assistance program, or for which payment is requested or received, in whole or part, pursuant to a medical assistance program. Health Care Provider any person delivering or purporting to deliver, any health care, and including any employee agent or other representative of such a person, and further including any employee representative, or subcontractor of the State of Missouri delivering, purporting to deliver, or arranging for the delivery of any health care. 4

5 FRAUD: The obtaining of a benefit through the intentional misrepresentation or concealment of material facts. WASTE: The incurring i of unnecessary costs as a result of deficient management, practices, or controls. ABUSE: The excessive or improper using of government resources. This is when an individual or organization intentionally falsifies information for financial gain. One of the most common examples is a provider submitting claims to a payer for services that were never performed. Other types of fraud include upcoding, in which the provider bills for a higher CPT code than what was actually performed, and billing separately for services that should have been bundled together and billed at a lower cost. Fraud also occurs on the patient side, such as when an individual uses another person s insurance to receive care, or visits multiple doctors to obtain unnecessary prescriptions for drugs. This is what happens when providers misuse resources, which can occur intentionally or unintentionally. One example is writing prescriptions for expensive medications when low cost generic alternatives are available. On the more dangerous side are the examples of doctors performing inappropriate or unnecessary procedures. 5

6 Abuse is similar to fraud, except it refers to cases in which criminal intent can t be proven. It might occur when providers accidentally overcharge for services or use an incorrect code. While the law distinguishes between fraud and abuse, the end result to payers is the same the organization ends up paying money for something that shouldn t have been reimbursed. Some examples are: Overcharging for services provided Charging for services not rendered Accepting bribes or kickbacks kb k for referring clients Incentives to retain clients Rendering inappropriate or unnecessary services RSMo Any in home services provider agency or in home services employee who puts to his or her own use or the use of the in home services provider agency or otherwise diverts from the in home services client's use any personal property or funds of the in home services client, or falsifies any documents for service delivery, is guilty of a class A misdemeanor. 6

7 This would include: having clients co sign for loans, Buying cell phones, clothing, etc. Paying bills Occurs when the aide/attendant has obtained control over the clients property by deception, intimidation or force. Examples: Misuse of Power of Attorney, theft, stealing by deceit, undue influence in writing wills or other documents. Aide/attendant is believed to have falsified time sheets Examples: Leaving early Arriving late Not showing up but claiming li i time worked kd Being in two places at the same time 7

8 No documentation Documentation for services delivered by the provider must include the following: A. The recipient s name and B. The date of service; C. The time spent providing the service If the documentation is not legible, then the service did not happen. Please make sure we can read your time sheets. No date Recorded Date must be on the time sheet, you can preprint the dates for service, but not the times Please make the dates legible 8

9 No clock times Do not pre print clock times on time sheets Clock times must be the actual time. Clock in/clock out time Number of Units exceed actual time worked Units must equal time worked 1 unit=15 minutes 5hours worked = 20 units Do not bill units from the Care Plan, bill from time sheets and only the time worked. No Tasks checked on Time Sheets If you do the work, check the task. If you did not do the task, don t check it just because you think it looks like you worked. kd Ironing/mending should not be checked every day. 9

10 Mark what was actually accomplished for that date of service For example, marking essential correspondence 7 days a week will make me take a closer look Aide not identified If you are the aide working, make sure your name is on the time sheet. And please make it LEGIBLE. AM/PM designations are helpful And please sign the time sheet. No participant (or responsible person) signature on time sheet. For each date of service: the signature of the recipient, or the mark of the recipient witnessed by at least one (1) person, or the signature of another responsible person present in the recipient s home or licensed Residential Care Facility I or II at the time of service. Responsible person may include the personal care aide s supervisor, if the supervisor is present in the home at the time of service delivery. The personal care aide may only sign on behalf of the recipient when the recipient is unable to sign and there is no other responsible person present. 10

11 Do not sign the participants signature. If you sign for the participant because he/she cannot, make sure it is noted somewhere on the time sheet. If a responsible party signs, again, make a note on the time sheet. Sign daily, not weekly, every two weeks, monthly or only on Fridays Again, Forgeries are Felonies. DO NOT SIGN THE PARTICPANTS NAME Aide can sign for the participant when he/she is unable to Responsible person to sign for the participant when the participant cannot sign would be a family member, or a supervisor from the company. Please make a note some where on the time sheet indicating that someone else signed for the participant This relates to both in home and RCF settings Initials are not permitted Time sheet is signed by aide not present at time of service delivery. You must sign the sheets daily. 11

12 If the Care Plan allows for 2 hours a day, do not put 4 hours just because it took you longer to do each task. You are only allowed what is allocated on the Care Plan. If the care plan needs to be adjusted, contact DHSS for a reassessment. Aide documents being in two places at once. Please make sure the time sheets are legible The provider should not submit claims solely on the basis of the prior authorization, but must base claims upon documentation of actual services rendered. 12

13 Actual Clock Times are required Providers, do not pre print the clock times on the time sheets Please start using am/pm designations Make times legible If you arrive at 1:15pm but your normal start time is 1:00pm, you need to put down 1:15pm as the time you began service A person commits the crime of stealing if he or she appropriates property or services of another with the purpose to deprive him or her thereof, either without his or her consent or by means of deceit or coercion. If you bill for services while the participant is in the hospital or otherwise not receiving services, you may be guilty of stealing. Medicaid can take the money back from the provider and in turn, the provider could sue you civilly for the money owed. Do not bill for services when the participant has died. MMAC will check data bases for deaths. If you are billing and getting paid when the participant has died, that is stealing and fraud 13

14 Follow the Care Plan as close as you can Never serve more than approved units If the Care Plan needs to be changed, contact DHSS Can t work for someone while you live out of state Can t collect a check for someone who failed the FCSR Can t be in two places at the same time i.e. Full time job or two different clients Planning, preparation, and clean up of meals; Making beds and changing sheets with the participant in or out of the bed, as required; Brushing, combing and shampooing hair; Giving bed baths and assisting with other baths; Brushing teeth and cleaning dentures when the participant is unable; Cleaning and cutting fingernails and toenails of participants without contraindicating conditions; Shaving with an electric or safety razor, as appropriate; an electric razor must be used for the diabetic participant or participant with contraindicating conditions; Giving assistance to and from the bed to a wheelchair, walker or chair when a participant is weight bearing; Assisting the participant with ordinarily self administered medications (open bottles, get water); Shopping for groceries or household items specifically required for the health and maintenance of the participant; and Personal care services are covered only in the participant s home Personal Care services are not covered in a hospital or nursing facility. 14

15 Personal care providers are not reimbursed for the following activities Providing therapeutic/health related activities that should be performed by an RN, LPN, or home health aide under Title XVIII or Title XIX Home Health Programs; Providing transportation or escort services; Administering patent or prescribed medications; Cleaning or cutting fingernails or toenails of a diabetic participant or a participant with circulatory problems, unless this service is performed by a nurse during an authorized nurse visit; Cleaning the floor and furniture in areas not occupied id by the participant. i t For example, cleaning the entire living area if the participant occupies only one small room; Laundry, other than that incidental to the care of the participant. For example, laundering clothing and bedding for the entire household, as opposed to simple laundering of the participant s bed smock or gown; Shopping for groceries or household items other than items required specifically for the health and maintenance of the participant. This does not preclude a personal care aide s shopping for items needed by the participant, but also used by the rest of the household; Providing personal care services to a participant by a member of the participant s family or household member; and Use the recipient s car Use the recipient s telephone for personal calls Discuss own or others' personal problems or religious or political beliefs with the recipient Bring other persons to the recipient s home Consume alcoholic beverages, or using medicine or drugs for any purpose, other than medical, in the recipient s home or prior to service delivery Accepting money or goods for personal gain from the recipient Smoking in the recipient s home Breaching the recipient s privacy and confidentiality of information and records Purchasing any item from the recipient even at fair market value Assuming control of the financial and/or personal affairs of the recipient or the recipient s estate including power of attorney, conservatorship, guardianship Residing with the recipient in either the recipient s or worker s residence Taking anything from the recipient s home Committing any act of abuse, neglect, or exploitation 15

16 The Employee Disqualification List (EDL) maintained by the Department of Health and Senior Services is a listing of individuals who have been determined to have: abused or neglected a resident, patient, client, or consumer; misappropriated funds or property belonging to a resident, patient, client, or consumer; or falsified documentation verifying delivery of services to an in home services client or consumer. These acts must have occurred while the individual was employed or by reason of their employment by a long term care facility, an in home services provider agency, by a hospital, home health agency, hospice, or ambulatory surgical center, or by a consumer or vendor. MMAC works closely with DHSS and DSDS. Consumers receiving personal care assistance services shall be responsible for: (1) Supervising their personal care attendant; (2) Verifying wages to be paid to the personal care attendant; (3) Preparing and submitting time sheets, signed by both the consumer and personal care attendant, to the vendor on a biweekly basis; (4) Promptly notifying the department within ten days of any changes in circumstances affecting the personal care assistance services plan or in the consumer's place of residence; (5) Reporting any problems resulting from the quality of services rendered by the personal care attendant to the vendor. If the consumer is unable to resolve any problems resulting from the quality of service rendered by the personal care attendant with the vendor, the consumer shall report the situation to the department; and (6) Providing the vendor with all necessary information to complete required paperwork for establishing the employer identification number. 16

17 The attendant may be a family member but cannot be a spouse. As a Consumer, you are also responsible for correct time sheets. Your signature on the time sheets verifies that everything is correct. If you knowingly sign a time sheet that t is false, you can be: Removed from the CDS program Placed into In Home services Re evaluated to see if you even need services Prosecuted for fraud Sign your time sheet daily Make sure you look at your time sheet daily Make sure you mark hospital if you were in the hospital any time during the week Make sure the dates and times are correct Do not sign your time sheet for a week or more in advance Make sure the chores that are marked were completed If you are not home, it is very hard for your aid/attendant to provide services to you. 17

18 As a consumer who is directing his or her own care, it is your responsibility to make sure your time sheets are correct and your care plan is being followed. If you cannot be responsible, you can be removed from CDS and placed into a different program where your decisions are made for you. You can be re evaluated to see if you even need services. Prosecution is also an option if you are determined to be engaging in fraudulent activities. (1) Collecting time sheets or reviewing reports of delivered services and certifying the accuracy thereof; (2) The Medicaid reimbursement process, including the filing of claims and reporting data to the department as required by rule; (3) Transmitting the individual payment directly to the personal care attendant on behalf of the consumer; (4) Monitoring the performance of the personal care assistance services plan. Just to summarize: Clock time must be actual time in and out You cannot be at two places at once Do not sign the participants name Forgery is a Felony Do not submit a time sheet for days when the participant is dead or in the hospital Sign the time sheets daily 18

19 You can reach me at: Mike Valley Web site: mmac.mo.gov MMAC Fraud E Mail: MMAC.ReportFraud@dss.mo.gov Participant Services: Provider Education Unit: Provider Relations Communication Unit: Manuals.momed.com 19