The bill sent to the state by a Minneapolis home care business was incredible: A personal care assistant helping the sick or disabled had worked 32 hours a day, for three days in a row.
But the state paid it.
"I'm really surprised it went through," said Colleen Williams, director of Circle of Life Home Care Anishinaabe Inc., who recently paid the state back when she discovered the mistake.
In at least 21 similar cases since last summer, the state Department of Human Services paid agencies where care attendants supposedly worked more than 24 hours a day, a Star Tribune investigation has found. In hundreds of other cases over the past year, records show, the department also failed to enforce new limits on the number of hours that caregivers are allowed to work. Those caps were imposed to control costs and keep clients safe from overworked caregivers.
State administrators promised last year to do a better job of overseeing the fast-growing, multimillion dollar state program, which provides help to disabled people in their homes, after a 2009 legislative audit found that it was "unacceptably vulnerable to fraud and abuse."
But the state's inability to catch obvious cases of overbilling is reviving questions about its capacity to guard against Medicaid fraud.
"There is no excuse for that,'' said Sen. Ann Rest, DFL-New Hope, chairwoman of the Legislative Audit Commission. "I would have thought they would be on top of this because the [auditor's] report caused quite a stir at the time."
Allegations of fraud in personal care assistance have been common in Minnesota and around the country. The program accounts for just 10 percent of the state's total Medicaid spending, but consumes two-thirds of the time devoted to investigating questionable care by the state Department of Human Services, according to the January 2009 audit.
Rest said the program is important because it gives families a choice when it comes to deciding what to do with aging or disabled relatives who need help with simple tasks they can't handle by themselves, such as eating, bathing and dressing. By using personal care assistants, thousands of Minnesotans have been able to remain at home, a much cheaper option than sending them to nursing homes or group homes.
Limits imposed in 2009
The program has grown quickly. From fiscal year 2002 through 2007, publicly funded expenses jumped 164 percent, from $153 million to about $400 million a year, the audit report said. About 32,000 people received services in 2009.
Legislators and department officials imposed limits last year on the number of hours that can be worked by personal care assistants: 16 hours in a single day and 275 hours in a month. The caps were instituted after the Legislative Auditor revealed more than 400 improper payments in a single month to companies that claimed caregivers worked more than 24 hours a day.
The department's error rate appears to have declined, but costly mistakes continue to slip past administrators. At least 98 times since last July, the department approved payments for care attendants who exceeded the monthly limit, according to the Star Tribune's analysis of more than 4 million billing records. In another 465 cases, records show, the department approved payments for workers who surpassed the 16-hour daily limit.
State officials blamed the overpayments on computer programming errors, which they say they have fixed. Officials acknowledged, however, that they were unaware of the problems until the Star Tribune pointed them out. Officials said the department is working on new ways to flag such irregularities.
"We clearly need to improve our integrity to the payment claims," said Loren Colman, assistant commissioner for continuing care at the Department of Human Services.
The department said it suspended the 16-hour rule in March because it created too much confusion. Officials said the rule limited flexibility and might result in some people missing out on the help they need.
The department's lapse in oversight could bring more scrutiny from the Legislative Auditor's Office.
"If there are cases like that that have continued, yeah, it would be an issue. It would indicate that DHS is not yet effectively catching cases that it thought that it should be catching," said Joel Alter, who managed the care assistant study for the Legislative Auditor.
Department officials believe overpayments for individuals claiming more than 24 hours of work in a day totals about $24,000 in the last 16 months, but they didn't have estimates for the other billing errors.
"Where we have exceeded our authority to pay beyond the limited hours, we will recoup that money," Colman said.
254 hours of work in one day?
The most egregious payment spotted by the Legislative Auditor involved a personal care worker who supposedly worked 254 hours in a single day in May 2008. At the time, the state did not even have a system for flagging such impossible claims, Alter said.
Darlene King, the personal care worker, said nobody from the state ever contacted her about the bill, which was submitted on her behalf by her employer, Plymouth-based Best of Care Inc. In fact, King said she never claimed that many hours, never received the money and was working about five hours a day at the time.
Company owner Lillian C. Richardson couldn't be reached for comment. Best of Care stopped billing the state in 2008. Records show that Paxton Richardson worked for his wife's company as a care assistant, but he told the Star Tribune he was not involved in the agency's billings and doesn't know why his wife closed the company.
"That's her business," Richardson said. "I just didn't get into it. I just did my own thing."
Richardson said he and his wife are separated and he didn't know how to reach her. In 2009, he started billing the state under his new care company called All Love Inc.
Department of Human Services officials would not discuss the 254-hour claim. They said the legislative audit prompted investigations of suspicious claims, but were unable to provide details on what happened in those cases.
However, department officials said that since the beginning of 2007, the agency's investigative division has recovered $3.2 million in 478 personal care assistance cases. The department referred 119 cases of suspected fraud involving personal care assistants to the Minnesota attorney general over that period, according to attorney general's office.
Department officials believe the scope of the problem is much broader. But with just 10 investigators, "We can't possibly investigate all that we need to," said Vicki Kunerth, who oversees the agency's investigative division.
Fraud cases bring convictions
Kunerth said the agency looks for patterns and tries to develop tools to prevent improper bills from getting paid in the first place.
But that hasn't always worked.
Since January 2007, the state attorney general pursued 57 criminal cases involving personal care assistance fraud, resulting in 35 convictions, five guilty pleas, 10 civil settlements and one acquittal. Six cases remain open. Courts have ordered $1.6 million in restitution. Another 31 investigations are ongoing.
Some cases are pursued by federal prosecutors. In April, the owner and two employees of Advance Home Health, a Brooklyn Park care company, pleaded guilty in connection with defrauding Medicaid of at least $200,000 by falsifying timecards and billing the state for hours they never worked. The workers gave clients part of their paycheck for participating in the deal, according to a federal indictment.
For one client, the firm billed the state for 5,352 hours over two years when the care attendant had actually worked less than five hours, according to the indictment. The defendants are awaiting sentencing in federal court.
In another case, the state paid bills for a client who was no longer living in Minnesota. Tammy T. Spraggins, 34, approved false time sheets saying her mother, Carol J. Moore, 50, and another relative were caring for Spraggins' 8-year-old son in 2006 and 2007. But Spraggins' son had been removed from her custody and was living with an aunt in East St. Louis, Ill. Prosecutors alleged the state was overbilled nearly $33,000.
The two pleaded guilty in Hennepin County District Court to felony theft by false representation. Spraggins was put on five years of probation and ordered to pay $10,000 in restitution. Moore was sentenced to five years of probation and 28 days of community service. She was ordered to pay $18,000 in restitution.
State officials can't constantly monitor whether care is being provided inside people's homes, but a new law is supposed to strengthen supervision of the industry.
Advocates for disabled people say there are bound to be billing mistakes in a large and fast-growing program, but they said limiting access to care is hurting those who need it. As nurses reassess their clients' needs and cut back on authorized hours of care, more clients will wind up needing expensive emergency room visits or hospitalizations, advocates argue.
"I think we're all in favor of oversight and strict auditing because the clients really need the service," said Pamela Hoopes, legal director of the Minnesota Disability Law Center. "If there isn't good oversight, then it places this really valuable and generally quite cost-effective service in jeopardy because it makes it a target for cuts."
Glenn Howatt • 612-673-7192 Pam Louwagie • 612-673-7102