Your affiant, Sergio Fernandez, is an investigator with the Medicaid Fraud Control Unit (MFCU) of the Minnesota Attorney General’s Office. As an investigator in the MFCU, I investigate allegations of billing fraud by health care providers enrolled in the Minnesota Medical Assistance Program (Medicaid). In this capacity, I investigated Faduma Ahmed Ali [DOB REDACTED] (ALI), Defendant herein, and determined that ALI defrauded the Medicaid program by submitting claims for Personal Care Assistance services (PCA services) and Homemaker services that she did not provide.
I determined that ALI could not have provided these services because the times she claimed to provide the services overlapped with times she worked in person at another employer, overlapped with each other, overlapped with times she provided these services to another recipient, or while the recipient was out of the country. As a result of these false claims, UCare and the Minnesota Department of Human Services (DHS) paid $27,617.44 in Medicaid funds, $17,391.00 of which was paid in wages. I. THE MEDICAID PROGRAM The Medicaid program provides medical care and services to low-income Minnesotans (recipients) who meet certain income and other eligibility requirements.
The Minnesota Department of Human Services (DHS), located in St. Paul, administers the Medicaid program. DHS contracts with or enrolls Personal Care Assistance Provider Agencies (Agencies) to furnish health care services to Medicaid recipients. Agencies that contract with DHS submit claims directly to DHS to receive reimbursement for services. DHS also contracts with managed care organizations (MCOs) to cover the costs of Medicaid recipients’ services on a managed care basis. When a recipient receives coverage through an MCO, providers submit claims directly to the MCO rather than to DHS for the services they provide to recipients.
On the relevant dates in this Complaint, UCare was an MCO. A. PCA Services Under Medicaid guidelines, Personal Care Assistant (PCA) services are provided by a PCA who is employed by an Agency to provide personal care to a recipient. PCA services include assistance with activities of daily living like dressing, grooming, bathing, eating, mobility, and toileting. PCA services occur in a recipient’s home. Agencies must submit background study requests, enrollment applications, and provider agreements for each of their PCAs before they provide services to recipients.
Medicaid also offers a shared care option for recipients of PCA services. Shared care services are provided in the same setting at the same time by the same PCA for multiple recipients. Shared care PCA payment rates, which are different from individual PCA service rates, apply if a PCA is providing shared care services. Shared care services must be approved by an assessor before the services are rendered. Additionally, any recipients receiving shared care services must have signed the Home Care Shared Services Agreement and been approved by the Agency for shared care services.
