Medicaid program integrity
Consumer Directed Services is paid for with public money. Every hour billed is a claim that the work was performed as described. Most problems in this program are not sophisticated schemes — they are ordinary people signing something they should not have, often to be kind.
What fraud looks like in CDS
These are the patterns that actually occur:
- Billing for hours not worked. The attendant was not there, or was there for less time than claimed.
- Pre-signed or blank timesheets. The consumer signs in advance and the hours are filled in later.
- Billing during a hospital or facility stay. The consumer was an inpatient and could not have received home care.
- Billing for unauthorized tasks. Real work, genuinely helpful, but outside the authorized care plan — yard work, caring for other household members, home repairs.
- Overlapping claims. One attendant claiming the same hours for two consumers.
- Kickbacks. An attendant paying the consumer a share of wages, or a consumer demanding one, in exchange for signing timesheets.
- Falsified EVV. Recording visits from somewhere other than where the work happened, or having someone else record on your behalf.
The consumer and the attendant are both exposed. Because both parties sign the timesheet, both are making the claim. A family caring for a parent can find that a favor — “just sign it, you were here most of the week” — becomes a repayment demand and a criminal referral.
Waste and abuse
Not every problem is fraud. Waste is spending that produces no benefit — duplicated services, or care plans that no longer reflect what someone needs. Abuse is practice inconsistent with sound fiscal or program standards, without the intent that fraud requires. Both still have to be corrected.
A care plan that has drifted out of date is a common one. If your needs have reduced, say so and ask for a reassessment. If they have increased, do the same — the plan is meant to match reality in both directions.
The laws that apply
| Authority | What it covers |
|---|---|
| Federal False Claims Act (31 U.S.C. §§ 3729–3733) | Civil liability for knowingly presenting false claims for federal payment, with substantial penalties and treble damages. |
| RSMo 191.905 | Missouri’s health care payment fraud statute, covering false claims for health care payments. |
| Anti-Kickback Statute (42 U.S.C. § 1320a-7b) | Prohibits paying or receiving anything of value to induce federally reimbursable services. |
| Exclusion authority (42 U.S.C. § 1320a-7) | Individuals and entities can be barred from participating in federal health care programs. |
What we do about it
- Verify timesheets against authorized care plans and EVV records before payroll.
- Cover fraud, waste and abuse explicitly in attendant orientation and consumer orientation.
- Investigate discrepancies rather than quietly paying them.
- Cooperate fully with MMAC, DHSS and law enforcement reviews and audits.
- Maintain the records the program requires, for the periods required.
- Protect people who report concerns in good faith from retaliation.
How to report
To us: call (314) 809-6655 or email info@communicareelite.com. You may report anonymously.
To the state: Missouri Medicaid Audit and Compliance (MMAC) receives provider fraud referrals. The Missouri Attorney General’s Medicaid Fraud Control Unit investigates Medicaid fraud and abuse of residents in care.
To the federal government: the U.S. Department of Health and Human Services Office of Inspector General operates a fraud hotline at 1-800-HHS-TIPS.
If you are worried you already did something wrong
Call us before someone else finds it. An error you disclose and correct is a different situation from one discovered in an audit — in intent, in consequence, and in how it is treated. This is genuinely worth acting on today rather than hoping.
Have a concern? Raise it.
Call (314) 809-6655 for a free consultation, or text (314) 886-5902. We serve St. Louis City, St. Louis County and Missouri communities within about 40 miles of our office.