Splitting the Difference

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Medicaid offers a Personal Care Assistant (PCA) Program that provides assistance for those who are experiencing chronic health care issues or difficulty in completing functions necessary for daily living. The program, which is administered at the state level, provides in-home, non-emergency health related services to medically eligible beneficiaries. An article published by Insurance Fraud NEWS covers one Illinois woman who served as her sister’s PCA and fraudulently billed Medicaid for services she did not provide.

The story states that the biggest fraud problem within the Medicaid program reported by states nationwide is the PCA Program. The PCA program is vulnerable to fraud because Medicaid recipients are allowed to control the selection of the PCA, making it possible for a relative or family friend to serve as a ”ghost” employee. (This means that there is a huge opportunity for deceptive people to collect compensation for services that were never provided.) And, that is exactly what happened in this case. The 49-year-old woman, who served as her sister’s personal assistant, billed Medicaid for hours that she was not providing care for her sister and when the sister was hospitalized. Then, she allegedly split the reimbursement check with her ill sister. (That sounds like pretty easy money.)

The fraudster is facing a maximum prison sentence of 10 years, a $250,000 fine and three years of supervision.

It’s a certainty that the care-taker sister will not be splitting the prison term with anyone. She’ll be required to face the consequences for her criminal actions all on her own.

Source: Today’s ”Fraud of the Day” is based on an article entitled ”Florissant Woman Guilty of Medicaid Fraud for False Billing as Sister’s Assistant” published by Insurance Fraud NEWS on March 21, 2014.

Florissant, IL — Tisa Vaughn of Florissant was found guilty of Medicaid fraud for false billing related to the care of her sister in East St. Louis, the U.S. Attorney’s office announced Thursday.

Attorneys said Vaughn, 49, was listed as a personal assistant for her sister, who was on Medicaid. Vaughn billed the government insurance program for hours when she wasn’t with her sister or when the sister was in the hospital. The sisters then split the money they received from Illinois’ home services program, according to evidence presented at trial.

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Larry Benson is currently the Director of Strategic Alliances for Revenue Discovery and Recovery at LexisNexis Risk Solutions. In this role, Benson is responsible for developing partnerships for the tax and revenue and child support enforcement verticals. He focuses on embedded companies that have a need for third-party analytics to enhance their current offerings.