Program Integrity

Program Integrity are bills and initiatives that safeguard taxpayer dollars.  These bills directly target government policies and practices that may create waste, fraud, and abuse diverting tax dollars away from their rightful policy intentions.  


House Republican Program Integrity Bills

•	False Claims -  HB 1437 (Grove)
	-  When an individual knowingly submits a fraudulent claim with the intent to defraud the government, that individual is liable for payment.
	-  Definition of “knowing” or “knowingly” means the individual had actual knowledge that the statement or claim was false.
•	National Provider Identification Number (NPI) – HB 876 (Cabell)
	-  In 2019, then PA Attorney General Josh Shapiro supported the grand jury recommendation that DHS should require anyone providing services under Medicaid in PA shall be identified with either a NPI or State Provider Identification (SPI).
	-  Provider identification will ensure proper documentation and accountability for processing payment and claims.
•	DO NOT PAY Initiative – HB 44 (Owlett)
	-  Establish a state database of organizations, individuals and entities which are not eligible to receive funds from a commonwealth agency.
•	Improper Payments – HB 971 (Gaydos)
	-  Defined as an overpayment/underpayment or a payment for an ineligible service or a payment to someone who was ineligible to receive it.
	-  Legislation requires agencies to review programs and expenditures and assess whether they are susceptible to an improper payment.
•	Provider Preventable Conditions (PPC) – HB 1105 (Scialabba)
	- PPCs-Health care acquired conditions in in-patient settings- which results in higher costs (e.g., Pressure sores/ hip fractures) OR an invasive or surgical procedure performed on the wrong person or body part.
	- Any Medicaid service provider who fails to keep proper documentation to ensure PPCs do not occur will face substantial fines.
	- The fines will serve as a deterrent to providers to ensure that providers do not file claims for egregious mistakes on part of the provider.
•	Stopping Medicaid and False Claims - HB 1439 (Kauffman)
	- Triple damages and enhance civil penalties to those who knowingly pursue false or fraudulent Medicaid claims.
•	Cross Checks for Medical Assistance – HB 421 (Hamm)
	- Verity eligibility by cross checking applicants for – lottery winnings, death records, employment and income, residency, and incarceration.
•	Work and Volunteer Requirements for Medicaid Eligibility - HB1800 (Scialabba)
	- Requires able-bodied adults between the ages of 18-65 to work or volunteer a set amount of hours for Medicaid eligibility.
•	Out of State EBT Card Management Program - HB 1453 (Warner)
	- Requires DHS to create an Electronic Benefits Transfer Card Management Program to develop electronic controls, oversight mechanisms, and follow-up procedures to detect and track fraudulent uses.
•	Securing EBT Card Transactions with Authorized Users - HB 1455 (Warner)
	- Requires authorized users for EBT cards to sign the same rights and responsibilities agreements as those who are eligible for benefits, holding all recipients and authorized users to the same standards of use
•	Grand Jury Recommendations for MA Fraud - HB 1355 (Kutz)
	- Increases the penalties for making a false claim against the commonwealth’s Medical Assistance to:
	-     A felony of the second degree if the fraudulent claim is $100,000 or more.
	-     A felony of the third degree if the fraudulent claim is between $2,000 and $100,000.
	-     A misdemeanor of the third degree if the fraudulent claim is less than $2,000.
•	Medical Integrity Waivers – HB 331 (Stambaugh)
	- Requires DHS to annually apply for the following waivers:
	-     Fraud lockout – prohibit re-enrollment and deny eligibility for up to six months for non-disabled, non-pregnant adults between the ages of 19-64 years who fail to report changes in circumstances impacting their eligibility.
	-     Redetermination waiver – enable DHS to redetermine eligibility every six months instead of annually.
	-     Suspension of automatic renewal and prepopulated forms to ensure redeterminations occur using correct information.
•	Commonwealth Grant Accountability and Transparency Act - HB 1579  (Marcell)
	- Requires the establishment of uniform administrative requirements, cost principles, and audit requirements for state and federal pass-through awards to non-federal entities.
•	Federal Funds Oversight  - HB 1277 (Grove)
	- Require the Office of the Budget and state agencies to complete a report prior to accepting federal funding.
	- Requires state agencies to create a transparency portal for federal dollars.
	- Requires the IFO to review current federal funding to ascertain the costs of federal strings attached to accepting the funds.

Press

Grove, House Republicans to Unveil Bills to Combat Fraud, Wasteful Spending of Taxpayer Dollars

PennLive: Recipients rack up thousands in Pa. food stamp card balances, raising questions about expansion (5/24/23)

“I don’t think we as a caucus are necessarily opposed to the increase but certainly Chairman Grove does have a point about the folks sitting on that amount of money but I think that’s very far and few,” said House Democratic Policy Chairman Ryan Bizzarro of Erie County. “Within the next month, we need to come to some sort of decision how we’re going to handle the governor’s request moving forward.”


PA Capitol-Star: Pa. lawmakers roll out bipartisan proposal aimed at curbing Medicaid fraud (1/13/20)

Shapiro said his Medicaid Fraud unit made 292 arrests resulting in 173 convictions and recovered $34 million for the state in 2017 and 2018*. But his office does not currently have the authority to go after companies that file fraudulent claims in civil court.
As a result, he said, “it’s possible, no, likely, that Pennsylvania is losing $3 billion a year to fraud,” he said.


Lawmakers Unveil Bipartisan Bills to Fight Medicaid Fraud and Abuse (1/13/20)


Fraud Cases Announced by the Office of the State Inspector General 

State Inspector General Charges 45 with Public Assistance Fraud in November 2023
The Office of State Inspector General (OSIG) filed public assistance fraud charges against 45 individuals during November 2023. The restitution owed to the Commonwealth in these cases totals $183,680. Additional cost savings will be realized as the defendants will be temporarily disqualified from receiving public benefits in the programs they allegedly defrauded.

State Inspector General Charges 41 with Public Assistance Fraud in January 2024
The Office of State Inspector General (OSIG) filed public assistance fraud charges against 41 individuals during January 2024. The restitution owed to the Commonwealth in these cases totals $ 202,973. Additional cost savings will be realized as the defendants will be temporarily disqualified from receiving public benefits in the programs they allegedly defrauded.

State Inspector General Charges 94 with Public Assistance Fraud in February 2024
The Office of State Inspector General (OSIG) filed public assistance fraud charges against 94 individuals during February 2024. The restitution owed to the Commonwealth in these cases totals $411,192. Additional cost savings will be realized because the defendants will be temporarily disqualified from receiving public benefits in the programs they allegedly defrauded.

State Inspector General Charges 87 with Public Assistance Fraud in March 2024
The Office of State Inspector General (OSIG) filed public assistance fraud charges against 87 individuals during March 2024. The restitution owed to the Commonwealth in these cases totals $345,405. Additional cost savings will be realized because the defendants will be temporarily disqualified from receiving public benefits in the programs they allegedly defrauded.

State Inspector General Charges 90 with Public Assistance Fraud in April, May 2024
The Office of State Inspector General (OSIG) filed public assistance fraud charges against 90 individuals in April and May of 2024. The restitution owed to the Commonwealth in these cases totals $716,496. Additional cost savings will be realized because the defendants will be temporarily disqualified from receiving public benefits in the programs they allegedly defrauded.

State Inspector General Charges 47 with Felony Public Assistance Fraud in June 2024
The Office of State Inspector General (OSIG) filed felony public assistance fraud charges against 47 individuals in June of 2024. The restitution owed to the Commonwealth in these cases totals $228,772. Additional cost savings will be realized because the defendants will be temporarily disqualified from receiving public benefits in the programs they allegedly defrauded.

State Inspector General Charges 48 With Public Assistance Fraud In October 2023

The Office of State Inspector General (OSIG) filed public assistance fraud charges against 48 individuals during October 2023. The restitution owed to the Commonwealth in these cases totals $214,029. Additional cost savings will be realized as the defendants will be temporarily disqualified from receiving public benefits in the programs they allegedly defrauded.


State Inspector General Charges 50 With Public Assistance Fraud In September 2023

The Office of State Inspector General (OSIG) filed felony public assistance fraud charges against 50 individuals during September 2023. The restitution owed to the Commonwealth in these cases totals $584,874. Additional cost savings will be realized as the defendants will be temporarily disqualified from receiving public benefits in the programs they allegedly defrauded.


State Inspector General Charges 48 With Public Assistance Fraud In August 2023

The Office of State Inspector General (OSIG) filed public assistance fraud charges against 48 individuals during August 2023. The restitution owed to the Commonwealth in these cases totals $236,411. Additional cost savings will be realized as the defendants will be temporarily disqualified from receiving public benefits in the programs they allegedly defrauded.

State Inspector General Charges 53 with Public Assistance Fraud in July 2023

The Office of State Inspector General (OSIG) filed public assistance fraud charges against 53 individuals during July 2023. The restitution owed to the Commonwealth in these cases totals $309,666. Additional cost savings will be realized as the defendants will be temporarily disqualified from receiving public benefits in the programs they allegedly defrauded.


State Inspector General Charges 43 With Public Assistance Fraud In June 2023

The Office of State Inspector General (OSIG) filed public assistance fraud charges against 43 individuals during June 2023. The restitution owed to the Commonwealth in these cases totals $202,064. Additional cost savings will be realized as the defendants will be temporarily disqualified from receiving public benefits in the programs they allegedly defrauded.

State Inspector General Charges 52 with Public Assistance Fraud in May 2023
 
The Office of State Inspector General (OSIG) filed felony public assistance fraud charges against 52 individuals during May 2023. The restitution owed to the Commonwealth in these cases totals $347,497. Additional cost savings will be realized as the defendants will be temporarily disqualified from receiving public benefits in the programs they allegedly defrauded.

State Inspector General Charges 55 With Public Assistance Fraud In April 2023

The Office of State Inspector General (OSIG) filed public assistance fraud charges against 55 individuals during April 2023. The restitution owed to the Commonwealth in these cases totals $291,826. Additional cost savings will be realized as the defendants will be temporarily disqualified from receiving public benefits in the programs they allegedly defrauded.


State Inspector General Charges 61 With Public Assistance Fraud In March 2023

The Office of State Inspector General (OSIG) filed public assistance fraud charges against 61 individuals during March 2023. The restitution owed to the Commonwealth in these cases totals $250,965. Additional cost savings will be realized as the defendants will be temporarily disqualified from receiving public benefits in the programs they allegedly defrauded.


State Inspector General Charges 33 With Public Assistance Fraud In February 2023

The Office of State Inspector General (OSIG) filed public assistance fraud charges against 33 individuals during February 2023. The restitution owed to the Commonwealth in these cases totals $151,802. Additional cost savings will be realized as the defendants will be temporarily disqualified from receiving public benefits in the programs they allegedly defrauded.


State Inspector General Charges 52 With Public Assistance Fraud In January 2023

The Office of State Inspector General (OSIG) filed public assistance fraud charges against 52 individuals during January 2023. The restitution owed to the Commonwealth in these cases totals $349,835. Additional cost savings will be realized as the defendants will be temporarily disqualified from receiving public benefits in the programs they allegedly defrauded.



Man charged with committing $1.5M pandemic fraud (msn.com)

90 people charged in Pennsylvania SNAP benefits, public assistance fraud worth $716K - CBS Philadelphia (cbsnews.com)

Pa. couple pleads guilty to role in conspiracy to commit healthcare fraud tied to York-based pain management practice | fox43.com

Pa. Man Gets 12 Years For $2M COVID-19 Funds Fraud - Law360

Mom charged for welfare fraud | News | northcentralpa.com

PA Body Shop Owner Imposters Accused of Insurance Fraud | FenderBender and ABRN

Multi-state unemployment fraud scheme, including Michigan, lands man in prison for 51 months (clickondetroit.com)

Lancaster County woman pleads guilty to COVID fraud scheme | ABC27

Five charged with $90K worth of opioid fraud in PA | 28/22 News (pahomepage.com)

Penn Medicine hired a convicted felon to run Pennsylvania Hospital facilities (inquirer.com)

Two charged in PA for $2.5M pandemic assistance fraud | Eyewitness News (pahomepage.com)

Pa. postal workers accused of unemployment fraud (wgal.com)

Pa. State Police arrest PennDOT employee for alleged driver's license fraud (abc27.com)

Four Convicted in $9M Medicaid Fraud Scheme - Franklin County Free Press (fcfreepresspa.com)

Over $800,000 in Medicaid Fraud Uncovered in Pennsylvania, Multiple Arrests Made - MyChesCo

Philadelphia Behavioral Health Provider Faces Federal Lawsuit for Alleged Medicaid Fraud - MyChesCo

Pa. Attorney General alleges Medicaid fraud in Philly for transit and home care (inquirer.com)

Former physician assistant from Altoona charged with $40k Medicaid fraud (wtaj.com)

AG Shapiro Charges More Drug and Alcohol Treatment Providers for Illegal Kickbacks, Taking Advantage of People in Recovery – PA Office of Attorney General

Newburg woman charged with Medicaid fraud (publicopiniononline.com)

Three sentenced in $87 million Medicaid fraud scheme | TribLIVE.com

Three busted in Medicaid fraud scheme – Delco Times

Three Montgomery County dentists bilked Medicaid for millions, a federal indictment says (inquirer.com)

Manor Twp. man charged in Medicaid fraud case for falsifying $95,000 worth of care | Community News | lancasteronline.com

PA Home Care Agency Charged with $100,000 Medicaid Fraud - Home Health Care News

3 plead guilty in large conspiracy to defraud Pennsylvania Medicaid - CBS Pittsburgh (cbsnews.com)

Sisters charged in Medicaid fraud scheme (wtae.com)

Maple Glen and Blue Bell dental practice owners charged in RICO scheme to defraud government (thereporteronline.com)

Attorney General: Brookville Woman Faces Medicaid Fraud Charges - exploreJefferson (explorejeffersonpa.com)

Doctors, landlord arrested in $2M pill-mill scheme that allegedly stole Medicaid information from homeless and veterans in Tioga (inquirer.com)

Grand Jury recommends charges for Berks-based home care agency owner in $488k Medicaid fraud scheme | Berks Regional News | wfmz.com

Attorney General’s Office Files Fraud Charges Against Health Care Worker - LevittownNow.com

Photos: 3 arrested in Medicaid fraud investigations (wtae.com)

Banned from Medicare, still billing Medicaid (reuters.com)

Bensalem Pharmacy Owner Fined $250K Over Alleged Fraud | Bensalem, PA Patch

Mental health company to pay $7.8 million fraud fine - Philadelphia Business Journal (bizjournals.com)

FOUR PHARMACISTS FINED IN MEDICAID FRAUD CASE – The Morning Call (mcall.com)

Dentist accused of billing Medicaid when patients brushed their own teeth - UPI Archives


Reports Published by the Office of the State Inspector General 

Pennsylvania Department of Human Services Investigation into High Balances on Supplemental Nutrition Assistance Program Accounts (OIG-13-0493-I-DPW)

Pennsylvania Department of Labor and Industry, Interest Charged to Claimants with Fault UC Overpayments (Executive Summary)

Act 141 UC Fraud Report


Other Resources 

Excellence in Government: Preserving Benefit Integrity - June 5, 2024

Excellence in Government: Preserving Benefit Integrity - May 30, 2024

Excellence in Government: Preserving Benefit Integrity - May 29, 2024

Grand Jury investigation into the Pennsylvania Medical Assistance (MA) Program Report

Government Oversight Committee Staff Report on Medicaid: Provider Fraud & Improper Payments