Four Home Healthcare Workers in Missouri Charged with Defrauding Medicaid - In Home Supportive Services Fraud

State programs pay home health care workers (IHSS in California) to take care of the non-medical needs of elderly and/or disabled patients who qualify for SSI. These services are performed at the patients' own homes since it is much less expensive than placing these patients in assisted living or nursing homes. 

This can be a great program. However, the concern about fraud threatens it. In addition, the individual providers are being targeted. These are not large companies but individuals who are often low paid workers. This article is to remind those providers to be careful and not to submit documents with false billing or entries on them regardless of the temptation. In California, it is considered Medi-Cal fraud.

Let's be clear. States are aggressively going after fraudulent billing in the home setting. California usually brings charges in state court but we can expect federal charges as well. Missouri just charged four individuals in federal court for billing for services not provided in November 2015, and they are expected to be sentenced in early 2016 following guilty pleas.

In Home Personal Care Worker Agency and Owners Agree to Civil Resolution of Federal False Claims Case in Wisconsin - Why Health Care Providers Need Compliance Plans

There has been an increased number of lawsuits filed under the qui tam – or whistleblower – provisions of the False Claims Act, which allows private citizens with knowledge of health care fraud on the state or federal government to bring a civil action on their behalf. These cases can also involve claims submitted to state Medicaid programs (Medi-Cal in California) since they are in part federally funded. 

I discuss below how to develop compliance programs so a health care provider can show that there are no "false claims" and reduce the risk of having a lawsuit filed against them. False claims are not claims that were negligent or mistakes. Instead, false claims only cover claims that were submitted with deliberate knowledge of the falsity of the claim or deliberate ignorance of the falsity of the claim. Compliance programs - even modest ones - help prevent a whistleblower from claiming that there was deliberate knowledge or ignorance. 

A recent case that was settled involved claims submitted for personal care worker services to the Wisconsin Medicaid Program. In California, this is known as the IHHS (In Home Supportive Services). The private citizen whistleblower alleged that Atlas Healthcare, Inc., and its owners, Deana Bajanen and Sheena Jones knowingly submitted false claims for personal care worker services to the Wisconsin Medicaid Program for patients that did not need the services or did not need the level of services for which Atlas billed the Medicaid program. Atlas is located in Wisconsin. 

City Councilman Charged With In Home Supportive Services (IHSS) Fraud For Billing Program While Mother Was Out Of The Country

There has been an increased filing of felony fraud cases involving California's In Home Supportive Services program. The latest to be charged is a Moreno Valley city council member who on August 12, 2013 was charged with eight felony counts relating to billing and collecting $15,000 for IHSS services provided to his mother while she was allegedly out of the United States in the Philippines and Taiwan. The felony charges included grand theft, filing fraudulent documents, presenting a false claim and fraud. The case is pending in Riverside County Superior Court.

The IHSS program is an excellent program in that it allows care to be provided at home and ultimately saves the State significant sums in hospital and nursing home costs.  However, the programs which are administered by local counties -- even though funded by Medi-Cal -- are being more aggressive on combatting fraud and billing for services not provided. Audits of these programs have criticized IHSS for being an open door for fraud and abuse. Since most caregivers are family members, friends or someone known to the beneficiary this increases the risk for fraud.

We have had a number of cases where billing was done for the Medi-Cal beneficiaries while the beneficiaries were out of the United States. Sometimes those cases were referred to the County by Social Security because the beneficiaries collected SSI while outside of the United States. Other times the issues were raised by on-site visits or care provided by family members who worked full-time at other jobs. We have also had cases where the person providing the IHSS services were out of the country while the services were provided. Other cases have involved the IHSS provider collecting the funds and hiring someone else to perform the services. And other cases involved claims that the total hours billed were not provided.

There are a number of ways that the County can refer a case criminally but the case often begins with an investigation. In those cases, it is important to find legal counsel before any interviews or incriminating statements are made. We have prevented a number of cases from being filed when involved at the beginning of the investigation. There are times, for example, when the billing errors were a result of not understanding the rules of the program. There are other times when there are suspicions but the government does not have any evidence of the wrongdoing and will not unless there is a confession by the caregiver. Other types of cases with difficult facts can be handled better if there is a strategy at the beginning rather than the time of an arrest. The city council member in the case referenced above resigned from his position due to this arrest and the charges are still pending with an arraignment scheduled for October 7.

Posted by Tracy Green, Green and Associates, Attorneys at Law
213-233-2260; Email: tgreen@greenassoc.com

New Emphasis On Prosecuting Fraud In IHHS, Med-Cal And CalWorks Programs: 9 Arrested In Los Angeles County

In Los Angeles County and California, there have been increased prosecutions for public benefits fraud. The Department of Health Services and the District Attorney's Office have targeted the In-Home Supportive Services (IHSS) Program since it is perceived that there is a significant amount of fraud by both the recipients (in failing to report all income) and the providers (many of whom are often family members or friends). CalWorks and Medi-Cal programs have also been targeted. The District Attorney's Office has a Public Assistance Fraud Division which specializes in these cases.

What is IHHS? IHSS provides services to persons who are over age 65, blind or have a disability to enable them to remain safely in their home.  IHSS lets family members and others to become providers and get paid for providing basic services (cleaning, cooking, laundry, shopping, etc.) to individuals who cannot safely perform their services themselves due to physical or mental incapacity.  Cal. Welf. & Inst. Code § 12300(a).  Basically, IHSS is an alternative for individuals who might otherwise be placed in a facility when they are unable to care for themselves in their own home.This is an excellent program which saves the state money in the long run since it is much less expensive to keep individuals in their own home than to pay for nursing homes.

Last year, there were grand juries in six California counties which pointed out the lack of safeguards to protect against fraud. In 2009, Governor Schwarzenegger contended that 25% of the IHSS program was fraud even though there were no real statistics to back up that claim. This has created a political climate where these programs will be targeted for fraud investigations. While no one endorses fraud, the government should be careful not to single out Californians who need assistance to live at home and the people who help them stay safe and healthy.

Recent Los Angeles County District Arrests

During the week of May 24, 2010, nine people were charged by the Los Angeles County District Attorney's Office as a result of investigations by the District Attorney’s Office, the Department of Health Services and the Los Angeles County Department of Public Social Services. Two of the cases involved alleged losses of $45,000 and $395,000 while the remaining seven cases were much smaller with losses ranging from approximately $700 and $15,500. Most of the smaller seven cases involved alleged IHHS fraud.

(1) Ms. Alicia Garcia, age 51 of Los Angeles was charged in case LASC Case No. BA370996 with (i) one count of false statements to receive healthcare, (ii) three counts of aid by misrepresentation and (iii) four counts of perjury by false application for aid. It is alleged that Ms. Garcia received more than $136,000 in welfare benefits from January 2002 to April 2010. During the aided period, Ms. Garcia allegedly failed to report her true income, ownership of property, vehicles and bank accounts and also failed to report a spouse in the home.

Ms. Garcia's bail was initially set at $45,000. It is the D.A.'s Office practice to initially set bail at the amount of the loss in a fraud case. The maximum punishment for these offenses is a maximum state prison term of nine years although sentences in these type of cases are generally much lower and probation is available even if there is a guilty plea. 


(2) Ms. Tangela Ridgeway, age 35 of Cerritos, allegedly received more than $60,000 in public assistance benefits from June 2004 to March 2010, and is accused of failing to disclose that she owned a business, property and several vehicles. Ms. Ridgeway allegedly failed to report employment, underreported income and failed to disclose bank accounts. In LASC Case No. BA371480, Ms. Ridgeway is charged with (i) one count of aid by misrepresentation, (ii) one count of perjury by false application for aid, and (iii) 14 counts of perjury by declaration. Ms. Ridgeway's bail was initially set at $395,000 - indicating a larger loss amount - and she faces a maximum term of 19 years in state prison which again is subject to negotiation between defense counsel and prosecutors.

In Ms. Ridgeway's case, the D.A.'s Office may have 1099 statements from employers and banks to substantiate its claims. For over 7 years, there was a lawsuit which precluded the County from receiving 1099 and W-2 information from the Franchise Tax Board in order to conduct audits. This issue was decided in favor of the County approximately two years ago and there are a number of audits being conducted to compare the 1099s and W-2 reports to what applicants reported to programs such as CalWorks, Medi-Cal and IHHS.


The loss attributed to the seven others charged ranges between approximately $700 and $15,500 from such public assistance programs as In Home Supportive Services and CalWorks. The majority of those arrested were participants in the IHSS system which permits providers to receive money for services to elderly or dependent adults.

Attorney Thoughts

If you or a family member are audited or asked to come in for an interview with any government program, you should consult a public assistance fraud attorney. If one receives assistance, there are a number of documents that are signed over time under the penalty of perjury. Similarly, if one is an IHHS provider, there are a number of timesheets that are completed over time. Even if you have received benefits, you still have your rights under the Fifth Amendment not to incriminate yourself. You should understand your rights and analyze whether there is any exposure before you meet voluntarily with government investigators.

Posted by Tracy Green, Esq.  Any questions should be directed to Tracy Green, a very experienced IHHS fraud attorney, Medi-Cal fraud attorney and California public benefits fraud attorney. You can email her at tgreen@greenassoc.com or call her at 213-233-2261.


The firm focuses its practice on the representation of licensed professionals, individuals and businesses in civil, business, administrative and criminal proceedings. They have a specialty in representing health care providers  in health care fraud and other types of fraud and overbilling allegations in California and throughout the country. Their website is: http://www.greenassoc.com/