Improperly trained home health aides result in fraud charges

Medicaid billed for visits performed by aides

A two-year investigation of the home care industry in New York has resulted in the indictment of B&H Health Care Services, also known as Nursing Personnel Homecare, a Brooklyn, NY-based home health agency. According to the indictment, agency management knew that home health aides had not received proper training for the services they provided. That lack of proper training made the aides' services ineligible for the $30 million in Medicaid fees for which the agency billed New York and received payment.

In New York, home health aides must complete a minimum of 75 hours of training from a training program licensed by the Department of Health or the State Education Department. Sixteen of those hours must be supervised practical training conducted by a registered nurse. In addition to the indictment of the home health agency, charges have been filed against two people who helped the agency hire the aides and arranged for them to receive certifications from training schools without the required training.

Although the New York training requirements and the involvement of home health aides training schools may differ from the experience of agencies in other states, the experience in New York is a "harbinger of what is coming," says Robert W. Markette Jr., a home health attorney with Gilliland, Markette & Milligan in Indianapolis. "Home care fraud enforcement is picking up in all states," he says. States are looking carefully at kickbacks, suspicious profit-sharing programs, and false claims, he adds.

The reason that New York is important is that staff training and competence became an issue in the fraud case, says Markette. Although training requirements may differ from state to state, it is important that every agency document aide training and competency tests, he adds. "Every home health agency that bills Medicare must meet the Conditions of Participation requirement that staff members are certified to perform their jobs and that they pass competency tests related to their job responsibilities," he points out.

"In Indiana there are not a lot of training agencies, or schools to train home health aides, in fact, most home health agencies train their own aides," points out Markette. The only time an agency needs to be careful about accepting a training certification is if the aide is hired from another agency and does not repeat training at the new agency, he adds.

Although New York regulates aide training programs and requires agencies that want to train their own aides to submit a lengthy, comprehensive application that explains curriculum and teaching staff experience, the management at Home Aides of Central New York in Syracuse, NY, chose to provide the training program to the aides hired for the agency. In addition to classroom time, each aide spends two days shadowing an experienced aide, then the first three in-home visits by the aide are supervised by a nurse, explains Amy Kostyk, vice president of operations for the agency. Throughout the year, a nurse will supervise aide visits on a random basis, she adds.

The aide training program covers topics such as the patient's bill of rights, Health Insurance Portability and Accountability Act (HIPAA) privacy and security regulations, proper body mechanics for transferring patients, procedures to protect against bloodborne pathogens, personal care skills, and nutrition, explains Kostyk. "There is a written exam and every aide must pass a competency assessment that includes demonstration of skills," she adds.

During the training period, the aide is not an employee of the agency, points out Kostyk. "This gives us time to observe the aide's skills as well as his or her interpersonal skills," she explains. "If we see weakness in any area or a disinterest in the job, we ask the person to leave the program," she adds. If an aide requires extra training or additional supervision to master some of the skills, but they appear to be committed and interested in learning the job, they will get an opportunity to retake the tests, she adds.

Competency assessments key to training

A competency assessment is a critical part of evaluating an aide's training, says Markette. Medicare Conditions of Participation require competency assessments, and home health agencies should be documenting each assessment, he says. Competency assessments for aides that have been trained at other agencies also provide protection for agencies, he says. If an aide presents training certification from another source and passes your competency assessment, you can demonstrate that you had no reason to believe that the certification was not legitimate, he explains. "A home health agency is not required to investigate the credentials of a training agency," he adds.

A home health manager should pay attention to trends in competency assessments for aides trained through another organization, suggests Markette. "If you see that several aides with certification from the same organization consistently fail parts of the competency assessment, you should talk with the training organization," he suggests. Let them know what areas of the assessment pose problems for the aides and offer to review their curriculum to see if it addresses the areas included in your assessment. "If you have reason to believe that a training program might not be providing the education and you ignore the potential problem, then you could be at risk for hiring aides that are not trained appropriately," he explains.

If you are training your own aides, be sure that their job responsibilities are in line with guidelines set by your state, warns Markette. "There is a question about the limits for home health aides in some states," he says. While an RN can administer medication, home health aides, in most cases, cannot, he says. "But is it administering medication if the pills are counted out and placed in pill boxes and the aide reminds the patient to take the medicine, and may hand them the pills that have been counted out?" he asks.

Because job responsibilities and types of patients may differ from agency to agency, be sure that the training aide that you hire matches the responsibilities that he or she will perform for your patients, suggests Markette. This is another reason to use a standardized competency assessment for your agency and have all new hires assessed before they are hired, he adds. "If a new hire doesn't pass a competency assessment, don't assume the training was inadequate," he says. "Some people don't test well, so be sure you give them a chance to receive additional training and supervision before they re-test," he adds.

Document visits accurately

In addition to making sure that your aides have the skills and training to perform the visits for which you'll bill Medicare or Medicaid, be sure, too, that they understand the importance of accurate documentation of visits, says out Markette. "While the lack of training in New York was part of the fraud, be aware of the potential for aides who claim visits that were never actually made," he says. This fraud risk probably applies to more agencies because not all states have the training requirements that New York has, he explains.

"Unfortunately, this type of fraudulent activity is hard for an agency to catch if families and patients participate in the deception," says Markette. "Aides typically stay with a patient for a longer period of time and see the patient and family members more often than a nurse," he says. The relationship that develops can make families want to protect the aide, even when he or she calls to tell them she can't come by. "I've heard of cases in which the family will call a number and punch a code to say that the aide is at the home and that the aide has left, even when the aide never visited," he says.

"We use a timesheet that the aide and the family sign at each visit," says Kostyk. "We also compare computerized timesheets with the signed timesheets to verify accuracy," she adds.

If there is a conscious decision by the aide to defraud the agency and Medicare, and the family is complicit, it is tough to uncover the fraud, admits Markette. "You can randomly call family members and patients to conduct patient satisfaction surveys and ask about the last time the aide visited," he suggests. In fact, every agency should have a protocol in place to check on all staff members and verify that visits are conducted, he says.

If there is an accusation of fraud, the agency should be able to point to their policy, document agency efforts to verify visits, and demonstrate that employees are told to file visit information correctly, says Markette. "Showing that the agency is not involved in the fraud and that agency staff took every step possible to prevent or uncover fraud is a good defense."


  • Amy Kostyk, Vice President of Operations, Home Aides of Central New York, 723 James Street, Syracuse, NY 13203. Telephone: (315) 476-4295. Fax: (315) 476-0538. E-mail:
  • Robert W. Markette Jr., Attorney at Law, Gilliland Markette & Milligan, 3905 Vincennes Road, Suite 204, Indianapolis, IN 46268. Telephone: (800) 894-1243 or (317) 704-2410. Fax: (317) 704-2410. E-mail: