Adult Protective Services Policy Manual
ParticipantFalsification and Fraud 1703.24
The Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS) performs the functions ofAdult Protective Service (APS) investigations and the administration of the Home and Community Based Service (HCBS) programs (i.e.In-Home/Agency Optionand Personal Care Assistance, Consumer-Directed Services (CDS)). The DSDS Adult Protective & Community Worker (APCW) may receive an Abuse/Neglect/Exploitation (ANE) report with allegations of falsification of service delivery documents or fraud involving a HCBS participant.
A. Participant Falsification of Any Service Delivery Document
During an investigation involving a HCBS participant in which falsification of service delivery documents (i.e. timesheet falsification) has been alleged by any reporter, the APCW may discover that in addition to the alleged perpetrator (AP), the reported adult (RA) who is the HCBS participant, is or has also been involved with the falsification. If this discovery is made, the APCW shall:
I. Review the report to determine if the Department of Social Services (DSS), Missouri Medicaid Audit and Compliance Unit (MMAC), the state entity responsible for investigatingparticipant and provider falsification/fraud, is currently involved.
- If an MMAC audit or review indicates a DSDS HCBS participant and/or their aide is signing documentation (i.e., timesheets) indicating services were provided when it has been alleged that they were not provided, MMAC will contact the Central Registry Unit (CRU) and provide information for an ANE report with the allegation of falsification. If applicable, CRU will attach any written report provided by MMAC to the ANE report in Case Compass.
NOTE: If the written report provided by MMAC exceeds Case Compass attachment size restrictions, CRU will forward the report to the APCW via email once the ANE report has been routed.
If MMAC is listed as the reporter, or thereport otherwise includes information that MMAC is or has been involved,the APCW shall contact the MMAC investigator to determine the current status of the case and coordinate investigative reviews.DSDS and MMAC maintain a Memorandum of Understanding (MOU) which allows the sharing of documentation and information related to a corresponding falsification investigation.
- Even though MMAC may be involved, the APCW ismandated to performan APS investigation for the AP to be considered for possible Employee Disqualification List (EDL) placement(See Policy 1702.90). The documentation gathered by MMAC, such as hospital billing records or HCBS timesheets, shall be requested by the APCW to use in the ANEreport investigation.
II.If the falsification allegations implicate the RA in addition to the AP and there is no indication that MMAC is, or has been, involved the APCW shall contact MMAC via email at o inquire as to whether their agency has an open case that involves the RA and the AP in order to coordinate investigations. If MMAC does not have an open case or documentation to provide,the APCW shall proceed with the investigation.
III. At the conclusion of the investigation, if there is reason to believe that the RA has been involved in the falsification of any service delivery documents, the APCW shall determine the RA’s HCBS program participation and after supervisory consultation, the APCW shall provide information to MMAC regarding the case so that MMAC may proceed with their investigation and/or corrective action related to participant or provider falsification.
In-Home/Agency Option Participant
Upon a finding of Reason to Believeof falsification for an RAreceiving IHS/Agency-Option services,the APCW shall:
- Add the role of AP to the RAin Case Compass,linking the RA to the allegation of falsification.The APCW shallprovide detail on the investigative findings in the Statement of Evidence and on the disposition of the case in the Investigation Summary.
If MMAC was not the reporter, or is not currently involved in an investigation involving the RA, the APCW shall:
- Consult with the Adult Protective Community Supervisor (APCS) to determine if the RA should be referred to MMAC for a participant falsificationinvestigation. After consulting with the APCS and making that determination, the APCW shall complete the MMAC Referral to Investigations Form (1703.24 Exhibit A) and email to MMACusing the email address . A copy of the referral shall be uploaded to the RA’s APS investigation in Case Compass.
Consumer-Directed Services Participant
Upon a finding of Reason to Believeof falsification for an RA receiving CDS, the APCW shall:
- Add the role of AP to the RA in Case Compass, linkingthe RA to the allegation of falsification and providedetail on the investigation findings in the Statementof Evidence and on the disposition of the case in the Investigation Summary.
- Review the investigation with the APCS to determine if DSDS will discontinue the RA’s participation in the CDS program and offer IHS/Agency Option Services. Section 208.924, RSMo indicates that a participant’s personal care assistance services may be discontinued if the participant has falsified records. When the RA is receiving CDS and the RA participates in the falsification of service delivery documents, the RA is in violation of program mandates and this could result in the discontinuation of the RA’s participation in the CDS program.
- If the RA’s CDS will be discontinued, the APCW shall follow theprocedures described inChapter 5: Adverse Action and Chapter 6: Appeals and Hearing Process of the HCBS Policy Manual or contact the APCW assessor or appropriate Regional Evaluation Team (REV) supervisor to coordinate the CDS programs discontinuation process.
If MMAC was not the reporter, or is not currently involved in an investigation involving the RA, the APCW shall:
- Consult with the APCS to determine if the RA should be referred to MMAC for a participant falsification investigation. If it has been determined that the RA will be referred to MMAC, the APCW shall complete the MMAC Referral to Investigations Form (1703.24 Exhibit A) and email to MMAC using the email address . A copy of the referral shall be uploaded to the RA’s APS investigation in Case Compass.
B. Participant Fraud
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I. MMAC Responsibilities:
To participate in HCBS, the participant must be Medicaid eligible, as determined by DSS. DSS’s designee, MMAC is responsible for identifying, investigating, and in some cases referring to law enforcement officials’ cases of suspectedfraud of the Medicaid Program by individuals receiving HCBS authorized by DSDS. MMAC investigates the following types of fraud:
- Selling prescription medications obtained through the Medicaid program;
- Forging prescriptions to obtain medications;
- Allowing someone other than the card holder to utilize a Medicaid card;
- Falsifying information to qualify for Medicaid services;
- Going to the emergency room for a condition that is not an emergency;
- Misusing or abusing equipment that is provided by Medicaid;
- Getting services from multiple providers of the same kind i.e., seeking or obtaining medical services, or both, from a number of like providers and in quantities which exceed the levels that are considered medically necessary by current medical practices;
- Trying to get more services than are necessary.
Only MMAC has the authority to investigate the allegations listed above. DSDS does not have the authority to investigate these allegations. During an MMAC investigation that involves any of the types of participant fraud referenced above, DSDS will need to be informed of any CDS participant program violations. If an MMAC investigation that involves a CDS participant reveals a credible allegation of fraud, MMAC will contact the Bureau of Program Integrity (BPI) to provide that information.
II. DSDS Responsibilities:
If contacted by MMAC regarding the participant fraud referenced above, BPI shall follow-up and determine whether the participant should be removed from the CDS program and offered in-home/agency option services. BPI shall work with the appropriate Regional Evaluation (REV) Team staff to coordinate discontinuation of CDS.
While doing anyAPSinvestigation involving an RA,the APCW may become aware that the RA is or may be participating in thetypes of fraud referenced above. In these circumstances, the APCW shall:
- Consult with the APCS to determine if the RA should be referred to MMAC for a fraud investigation. If it’s determined that the RA shall be referred, the APCW shall complete the MMAC Referral to Investigations form (1703.24 Exhibit A) and email the form to MMAC, using the email address of . A copy of the referral shall be uploaded to the RA’s APS investigation in Case Compass.
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Effective: 03/14