Attorney General’s Office Charges Home Care Worker with Overbilling, Medicaid Fraud

10- days after celebrating his 45 birthday, the  Pennsylvania Office of the Attorney General  charged a Philadelphia man with seven medical fraud related felonies that occurred authorities say in 2020 in which the suspect billed for more than 1270 hours of services he allegedly did not provide,

Keystone First (Keystone) and the Pennsylvania Department of Human Services – Bureau of Program Integrity (BPI) contacted investigators after these entities received a complaint regarding Jacob Young a home care worker from Philadelphia.

According to the anonymous tip, Medicaid recipient “L.D.” told a University of Pennsylvania Medicine employee that while employed as L.D.’s Direct Care Worker (DCW) with the home care agency Always Best Care, for months Young had not provided the services  as assigned. Further investigation showed that Young was employed by another agency, Vital Support Home Health Care (Vital Support), while working for Always Best Care, and there was potential for overlap among Young’s claimed DCW hours, investigators said.,

Young was assigned to provide services to Medicaid recipient “S.L.” through Vital Support, and to L.D. and eight other consumers – D.K.”, “S.H.”, “J.P.”, “C.W.”, “B.G.”, “E.S.”, “Β.Τ.”, and “B.M.” – through Always Best Care, the probable cause alleges.

S.L., L.D., D.K., S.H., J.P., C.W., B.G., E.S., and B.T. all were Medicaid recipients eligible to receive services  under the Community Health Choices (CHC) Waiver program

The CHC Waiver is a home and community based program that provides a variety of services to eligible individuals. One of the services available under this waiver is PAS with daily living. The CHC Waiver requires Medicaid recipients to select a Managed Care Organization (MCO) to administer their medical and other benefits. Home care agencies submit claims to MCOs, where the claims are reviewed and payments are issued to agencies. S.L., L.D., S.H., J.P., B.G., and E.S.’s MCO were AmeriHealth. D.K. and B.T.’s MCO was UPMC, and C.W.’s MCO was Pennsylvania Health & Wellness (PAHW). B.M. was not a Medicaid recipient, authorities said.

S.L. received services through Vital Support, located at 826 E Allegheny Ave in Philadelphia. Vital Support utilized EVV, a software used to allow DCWs to record and submit their claimed hours. Vital Support used the electronic time records to generate claims for payment from the MCOs, and to pay its PCAs based on their reported hours. The other consumers all received their PAS through Always Best Care, located at 668 Woodbourne Road, Suite 105, Langhorne. Always Best Care did not utilize EVV and instead relied on paper timesheets to monitor DCWs’ hours. DCWs complete the timesheets, which are then signed by the consumers and submitted to the agency in order for claims to be generated for payment (in Medicaid recipients’ cases, from the MCOs), according to investigators.

Special Agent Berner reviewed documents from Vital Support, including Young’s EVV data and employee records. She also reviewed records from Always Best Care, including Young’s employee file, pay stubs, and weekly timesheets. In each production of records, she also observed a copy of Young’s Pennsylvania Identification Card and Social Security card identifying Young as the applicant. Special Agents determined Young submitted time for overlapping hours worked while employed as a DCW for Vital Support and Always Best Care. The below spreadsheet illustrates these instances, amounting to at least 1270.75 hours in overlap and $26, 169.84 paid out by Medicaid through AmeriHealth, UPMC, and PAHW, the probable cause alleges.

Young was arrested, arraigned and released on unsecured bail by District Judge Charles D. Jonas earlier this month with a court date scheduled for April 24.