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Most Providers are out of the loop when it comes to the broad range of reasons as to how conflicts occur. Here are the five most common scenarios; I have named them (1) Operation Hustler (2) The Partnership (3) Family Affair (4) The Helpful Patient (5) The Crooked Agency.
1. Operation Hustler
This occurs when one individual, with legal authorization to work in the U.S. and who meets all Home Health Aide credentialing, certification & compliance requirements, registers to work at several different agencies. This individual, aka the "hustler", solicits illegal immigrants and offers them employment opportunities. The hustler accepts a case from agency A, duplicates Agency Photo Identification badges, with the other party's actual photo, and sends the other person to work under their name. A request is sometimes made to change the contact phone and address of the registered employee, but generally, the hustler opts to remain as the sole agency contact to ensure "quality control" over any offered & accepted assignments. To summarize, a hustler might have 5 to 10 conspirators, all reporting income under the same social security number. At times, the hustler will register with various agencies and purposely wait a month or so before accepting a case, hoping that with time agency members will be less inclined to recognize them when they drop off a time sheet or attend an in-service. The hustler attempts to stay under the radar, avoiding any additional attention during the orientation and keeping dialogue with agency staff members to a minimum. This criminal career can be quite lucrative, as a hustler typically charges a finder's fee, in addition to taking a percentage of the net income of each partner in crime.
One of many tell tale signs to look for as an agency representative: When an aide says they will call back after taking down the information for a new case offer, be aware that this person may in fact be checking availability with her pool of illegal aides.
 2. The Partnership
No it's not a sole proprietorship and no bylaws apply. "The Partnership" is when the patient and aide enter into a contractual agreement (highly unlikely to be legally binding). The patient applies & gets approved for home care services; the aide registers at an agency and negotiates a higher salary since she will refer her own patient. How do they get caught? It's called greed. Another patient is recruited, referred to a different agency with the same aide and the schedules often overlap. Agencies beware! These package referral deals, although sweet, may not be very kosher.
3. The Family Affair
Similar to the Partnership, this scenario involves the entire family - with generations working together to commit fraud. Older adult family members apply for Home Care services, often exaggerating their physical ailments and functional status to qualify. Another family member obtains their HHA certificate and registers with various home health care agencies as an aide, referring their mother-in law, aunt, cousin, etc. Having gotten away with this for so many years, these individuals become more greedy and brazen in their efforts to manipulate the cracks in the system. They then recruit other adult family members and neighbors to participate in this easy money scheme, using the same family member Home Health Aide. Conflicts are now detected because the family aide is working overlapping shifts with other "family members, oops! I mean patients".
Some red flags: When agencies attempt to verify time and attendance with patients (ie. family members), all have been coached to say, "The aide went to the store or is doing laundry". Upon persistent agency efforts to confirm attendance with the assigned worker, they are programmed to respond: "Don't bother me - I'm sick." Even with proper call in and call outs, and in the absence of any exception visits, there are rarely any aides available to speak with agency representatives even right after a clock in occurred.
4. The Helpful Patient
This situation occurs when a legitimate aide develops a rapport with the patient and then asks for sympathetic favors, such as having the patient clock in and out in his/her place. The helpful patient becomes adept at calling in for the aide exactly at the scheduled visit start time. The conflict is detected when a clock in occurs when the same aide has not clocked out from another patient. Here is a summary of a recent conflict occurrence of this type:
A Home Health Aide had back-to-back assignments with two different patients - one scheduled for 9am to 1pm, the other for 1pm to 5pm. The aide allegedly trained her second patient to clock her in at the scheduled visit start time and the patient was very diligent about it. The conflict presented itself when the aide stayed a little later with her first patient and clocked out at 1:15pm, while she was already clocked in at 1pm with her second patient. This 15 minute overlap identified on the Conflict report exposed prolonged Medicaid fraud activity on the part of this Home Health Aide. As part of due diligence investigative procedure, the addresses of both patients involved were checked and it was uncovered that there was a significant mile radius distance between the two residences. This 15 minute window period opened up a three year history of Medicaid Fraud and this case set a new precedence for auditing. The use of mile radius information from points of service may very well become the next trending factor.
5. The Crooked Agency
We know who you are. Don't think your former disgruntled coordinators and supervisors haven't spilled the beans about your fraudulent agency business practices - that you knowingly sending illegal immigrants to work with patients under a properly registered employee. Too many people working under the registered name leads to Scheduling overlaps. You're giving the rest of us a bad rap and most importantly, patients are being put at risk. Stop it!! | 
