A district attorney's vision: a task force approach to combating public assistance program fraud.

• Author: West, Laura

WHEN SACRAMENTO COUNTY District Attorney Jan Scully took office in 1995, she stressed stricter oversight in public assistance programs to combat fraud. At that time, there were 190,000 California recipients on the In Home Supportive Service (IHSS) rolls. Fast-forward 16 years, there are now 441,000 California IHSS recipients and the message has not changed: Untrained social service agencies cannot be in charge of policing themselves; law enforcement participation is key to prevent, detect, and prosecute public assistance fraud.

In 2009, in spite of vocal resistance from social service agencies and unions, Jan Scully created a first-of its-kind multi-agency, multi-disciplinary task force to combat fraud in the IHSS program. The district attorney's IHSS Fraud Task Force has seen impressive results in its first two years and offers a promising model for other prosecutors' offices to combat program fraud in their jurisdictions. A basic understanding of the IHSS program and how fraud was addressed both pre- and post-task force, is helpful in understanding how this can be accomplished.

Medicaid is a joint federal-state program. Every state operates its own Medicaid system within federal guidelines. IHSS is a Medicaid funded entitlement program in California designed to pay for services needed to keep income eligible aged, blind and disabled people safely in their own homes. Most states have some similar program with the underlying theory that it is less expensive to pay to have people cared for in their own homes rather than be placed in a costly skilled nursing facility, and it also provides a better quality of life.The program is administered on a county level, with county social workers evaluating applicants for eligibility, awarding service hours, and conducting yearly home reassessment visits. Once approved for the program, IHSS clients, also called recipients, become the employer of record and are responsible for hiring their care providers and approving their care providers' time sheets. IHSS thereafter pays providers for performing a variety of approved household management tasks (food shopping and preparation, laundry, cleaning) as well as for assisting with personal care and accompaniment to medical appointments.

Although Jan Scully had been raising red flags about the need for greater IHSS oversight for several years, after a 2009 Sacramento County Grand Jury report was released strongly criticizing the lack of fiscal integrity and programmatic controls in IHSS, Jan Scully's plan to address the issue was approved by the Sacramento County Board of Supervisors. Grand juries throughout California examined IHSS programs and found this "honor based" system (i.e. no oversight or outside verification of hours worked) was easily exploitable. Fragmented fraud prevention, detection, investigation and prosecution systems in place at the time were ineffective in addressing the ever-ballooning program costs.

The cost for this program is overwhelming. California Department of Social Services noted there were 441,000 IHSS cases open in January 2011 among the 58 counties in California. The cost in federal (50% share), state (33% share) and county (17% share) dollars for one month was 390 million dollars. In essence, this one public assistance program pays out over 4.5 billion dollars annually in California alone.

Those with a criminal history are not prohibited from participating in this billion-dollar honor system program. No convictions prevent a person from being a recipient. The only prior criminal convictions that statutorily bar a person from being an IHSS provider for 10 years are convictions for:

* Child abuse

* Eider abuse

* Fraud against a government health care or supportive services program.

Parolees with serious criminal records that would prevent them from getting a job at a fast food restaurant can get paid $10.40 per hour (the rate in Sacramento County) for unverified claims that they provided care to a friend or family member who is an IHSS recipient. Those convicted of child molestation, homicide, rape, robbery, identity theft, embezzlement, and a laundry list of other serious and/or violent crimes are free to work in this loosely monitored program.

Although program regulations dictate that recipient reassessment visits must be conducted every 12 months in most cases to confirm that services hours are still...