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An Aging population, Social Day Care and Medicaid Fraud

As life-expectancy increases and our population gets older, taking care of our aging population will most likely become a top priority. Concerns about social security benefits and Medicaid at present, but more importantly in the future, are issues that many are trying to find solutions to.

As life-expectancy increases and our population gets older, taking care of our aging population will most likely become a top priority. Concerns about social security benefits and Medicaid at present, but more importantly in the future, are issues that many are trying to find solutions to. Couple these concerns with the tremendous costs of nursing homes, assisted living facilities, home health care, as well as practically any other costs associated with getting older, and it makes you not only wish you will never get old, but how on earth people deal with this.

For many seniors and their families, coping with aging and finding a good solution to caring for loved ones is compounded by the fact that it is all so expensive. Many nursing homes and other similar facilities are funded by Medicaid. Preventing Medicaid fraud, for example making false claims about services carried out for a resident in a nursing home to get more money, is important in preventing health care dollars from being wasted and keeping health care costs down.

A background check can help you make a better decisionThe costs of nursing homes and assisted living facilities are tremendous. The annual cost in 2011 of a semi-private room in a nursing home was $78,110. For an assisted living, the annual cost is $41, 724 and the average costs of having a home health aide was around $21, 840 in 2011 ( Often, those who end up in nursing homes are those who need the most care and assistance, as well as those who may be more independent but are suffering from Alzheimers.

Facilities such as nursing homes require the most funding to keep up with costs and to be able to provide good care to the residents. The largest portion of funding is usually government sponsored funding from Medicaid and Medicare.

A report on Medicaid repayments to nursing homes commissioned by the American Health Care Association found that the 2012 Medicaid shortfall was projected to exceed $7 billion ( They also found that for a typical 100-bed facility in which 63 percent of residents rely on Medicaid for coverage, this shortfall would mean a loss of more than $500,000 annually ( I would imagine that for facilities that rely heavily on Medicaid, decreases in reimbursement make the facilities job more difficult; among other things, resulting in staffing shortages which greatly affect patient care.

This is not to say that all nursing homes that are bad or even down-right terrible are so because they don't get enough Medicaid funding. Some are bad because of terrible management and poor facilities, among other reasons. The point is that Medicaid is an important source of funding for many facilities that take care of older adults, and Medicaid fraud wastes health care dollars and diverts funding away from facilities that can really use it, and are doing their job properly.

According to the Office of Inspector General, U.S. Department of Health and Human Services, in 2012, Medicaid Fraud Control Units (MFCU) reported 1,337 convictions in fiscal year 2012, 982 of which were related to Medicaid fraud ( In addition: States reported $2.9 billion in recoveries for both civil and criminal cases handled by the 50 MFCUs.

In addition, this translated to a return on investment (ROI) of $13.48 per $1 expended by the Federal and State Governments for MFCU operations ( If you are interested in more detailed information, see the website. The following article is one example of Medicaid fraud occurs and how it can waste health care dollars.

The New York Times article titled Day Centers Sprout Up, Luring Fit Elders and Costing Medicaid, discusses the problems surrounding social adult daycare centers in New York. Some of the problems can be viewed in light of recent attempts by Governor Andrew M. Cuomo to redesign the Medicaid program. The Governor created a Medicaid Redesign Team (MRT) to examine the state's Medicaid program and try and reduce spending and create a more effective program (

Altogether, the redesign of the Medicaid program through the MRT is supposed to result in a multi-year road map that will lead toward a more efficient program and system that is affordable and will achieve better health outcomes for New Yorkers ( For more information on New York's Medicaid changes, visit the website The state is trying to reduce costs by providing other services to older adults, such as these social adult daycare centers which are less expensive, instead of institutionalized nursing home care which is far more expensive and may take people away from their families and friends (

According to a description on the National Care Planning Council website, there are two purposes to adult day care: First, it helps the care-recipient improve in health and activity level. And second it provides rest for the caregiver at home. In New York, these centers have increased from 40 in 2010 to 192 in the last year or so.

These centers are reimbursed by Medicaid through Managed care companies; Managed care for people receiving home services who are eligible for both Medicaid and Medicare is mandatory in New York as of 2012 ( Apparently, these social adult daycare centers also refer their clients to the managed care companies.

This model of social adult day care was supposed to provide an opportunity for older adults to socialize, make connections and receive help with care that they needed: Beneficiaries are supposed to be impaired enough to need at least 120 days of help with tasks like walking, bathing or taking medication. But managed care companies, not government agencies, are now mainly in charge of determining eligibility, typically by using nurses to assess each potential member (

This particular article points out that that some of these centers are recruiting members through cash incentives and free food ( One client describes one centers recruitment methods: If you get someone else, they give you $50. And each week, there's a certain amount of money. One day there's $5, a $10 grocery coupon, or an unlimited MetroCard. If you don't want the MetroCard, they offer $125 in cash (

There are thousands of nursing homes in the United States. Unfortunately, they are not all great or even good. In my opinion, nursing homes are never the ideal, but often one does not have a choice. Putting a family member in a nursing home does not make you part of any wrong-doings the facility is involved in such as Medicaid fraud. But it seems to me being informed about the facilities history, whether they were involved in something like this, can help you make a more informed decision about the facility.

The website, lists has some advice on finding a good facility. For example, there are consumer reports on nursing homes. Another good piece of information about a facility is its Form 2567, which is a report on the state's inspection survey of the facility (

In addition, it would be good advice to background check (more information on that here) those working in your or a family members home as a home health aide. This would be more of a concern for those hiring aides through a smaller home health care agency.

In a report titled Safe at Home? Developing Effective Criminal Background Checks and Other Screening Policies for Home Care Workers: State Summaries put together by the National Conference of State Legislatures describes each state's requirements for background checks for home care workers ( They also put together a document that charts each state's relevant statutes and/or regulations, who is required to complete a check, and disqualifying offenses among other state by state information. This page has a list of good services.

Finding a good way to take care of our ever increasing, aging population is important, especially in years to come. Preventing Medicaid fraud is an important aspect of dealing with this and keeping health care costs down and not wasting health care dollars.

No matter how you decide to care for your aging parents, it is likely to be costly.

Dave Jordan has been working with background checks since 2008. Reprinted with permission.