‘Your days are numbered’: DOJ, federal agencies target health care fraud, Medicaid schemers in Pennsylvania

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The Trump administration and the U.S. Department of Justice are ramping up investigations into health care fraud across Pennsylvania.

A new strike force field office in Philadelphia will more deeply investigate people and businesses that are suspected of defrauding Medicaid, a public health insurance program funded by federal and state dollars that supports people with low incomes.

Federal and state leaders announced the strike force unit, as well as new criminal charges against 19 people accused of defrauding Medicaid of more than $4 million through home health care schemes, on Tuesday in Philadelphia.

“Let me be clear: If you steal from hardworking Americans, if you steal from our fellow Pennsylvanians, your days are numbered. We are coming for you,” said Scott Brady, a former U.S. attorney in Pittsburgh who now leads the White House Task Force to Eliminate Fraud.

Brady joined Dr. Mehmet Oz, administrator of the Centers for Medicaid and Medicare Services, Pennsylvania Attorney General Dave Sunday, David Metcalf, U.S. attorney for the Eastern District of Pennsylvania, and officials from other federal agencies for the announcement.

Focus on health care fraud in Pennsylvania follows recent actions in California and Minnesota, where federal officials have deferred at least $1 billion in Medicaid payments for “suspected fraud and noncompliance.”

The intensified scrutiny of Medicaid and Medicare claims are part of the Trump administration’s larger campaign targeting what they consider “waste, fraud and abuse” in government spending.

Federal officials believe that a lot of suspected Medicaid fraud is happening specifically in the home health care industry, which includes family members, friends, neighbors and other people who become designated caregivers for disabled or ill residents.

Caregivers provide help with personal care and daily tasks of living like dressing, bathing, cooking, transportation, medication adherence and more, and they get paid for that work through Medicaid.

Home care jobs have skyrocketed in many states, including Pennsylvania, to dubious levels, Oz claimed. It could indicate that it has become an attractive area for “fraudsters” and “grifters” who are billing Medicaid for caregiving work that they aren’t providing, he said.

“The surge in enrollment of individuals in these programs is stunning,” Oz said. “It’s becoming a jobs program. Medicaid fraud in the state is costing taxpayers for care that was never delivered, or even worse, harmful.”

Pennsylvania launched its in-home health and personal care program for designated caregivers in 2018. Since then, Metcalf said it’s been difficult for state regulators and investigators to verify that specific services are being provided on any given day, even with electronic monitoring programs and phone apps that are used to track workers’ shifts in real time.

“Because the caregiver or the client behind closed doors simply can tap a button on their smartphone app or call in, and that record doesn’t actually establish that the person was actually there or providing health care service,” Metcalf said.

The 19 people facing criminal charges for suspected fraud include a home health aid who allegedly billed Medicaid for services she provided while incarcerated. Another person submitted claims for work at a time when they were hospitalized, according to the charges.

Other people facing fraud charges billed Medicaid while they were supposedly working other jobs, in court, traveling out of state or the country, or engaged in drug activities. In one case, a person has been charged for allegedly claiming over 8,700 overlapping hours of paid work.

Cases like this are not “victimless crimes,” said Sunday, who oversees the Pennsylvania Medicaid Fraud Control Section.

“This is not about someone merely working the system,” he said. “Every dollar stolen from these programs causes direct harm to someone who needs care and cannot afford it. And we have seen many dollars stolen through this pipeline.”

Lawmakers and leaders in mostly Democrat-led states have refuted the administration’s claims that fraud is widespread and extensive. Instead, they’ve argued that looming federal policy changes and funding cuts to the Medicaid program, championed by the GOP, will cause greater harm to vulnerable residents who rely on care provided through the public insurance programs.