MDCP*Workaround- Is this fraud?

Specialties Private Duty

Published

My infant vent Pt is already on Medicaid and is eligible for the Medically Dependent Children Program*here in Texas. I fully believe he qualifies for it and the need is there. It will provide great resources and Respite care.

Now normally it has a wait list that is over 5 years long. To circumvent this wait, there is a Rider 28 where if the child is in a nursing home and is then moved home they can go straight into the program. The SNF stay can be as short as overnight with a MD waiver. This is all fine by me.

The fishy part is when overnight is from 2230-0030. The SNF is paid for the use of the room in cash and then a single assessment is done by the facility's nurse. While remaining true to the letter of the law it just made me very uncomfortable. While probably not true fraud I feel this negates the purpose of the Rider 28 which is to bring institutionalized kids home.

Does anyone have experience with this programs like this?

jdub6

233 Posts

I am not in Texas and have no knowledge of that law. I am also not a lawyer. That said, from what you described, it sounds like it may well be legal. Working for for-profit entities has taught me that all systems have loopholes and those loopholes WILL be exploited. While it may not be ethical, it is not fraud unless it is specifically prohibited by the law/rider/whatever. So, you could look into it further and see if this program specifies a minimum length of SNF stay, but if not then it's not illegal. And it's probably fairly well-known among insiders in the state in that field and more common than you think, although if it costs the state enough money there may eventually be a length of stay stipulation written into it, but then someone will probably find a new loophole to use.

Sadly there is not enough money to go around and people get creative on how to get it. Like you said, your pt needs it now, not in five years...but you also said this isn't what this rider was meant to facilitate...there are no easy answers sometimes. But in answer to your question, just because it is unethical and not what the program was designed for doesnt make it fraud. It is only fraud if they are falsifying documentation or violating the specific requirements of the program.

caliotter3

38,333 Posts

If you feel strongly about this situation, you might want to consider writing a letter of concern to the appropriate authority, perhaps anonymously. By bringing this to their attention, you might be able to bring about change in the program implementation guidelines.

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