The industry though generating generous amounts of cash to these agencies is said to be lacking in the verification of its employees that carry out various health care needs. This is in sharp contrast to the scrutiny these agencies receive, add officials.
Incidentally, while there are two different offices that accredit programs to train home aides, there is no central registry of the tens of thousands of people who have been granted training certificates. This mans that state officials do not even know precisely how many home health aides work in New York.
"To make someone else's home fabulous, you need a license and your name goes in a state registry," says Jeffrey Lerner, a spokesman for the state attorney general, Andrew M. Cuomo. "But to care for someone in their home who is old and infirm, there is no central registry."
Cuomo is in the middle of a two-year investigation into fraud in the home health industry. This involves scores of cases involving schools that improperly issued training certificates as well as agencies that billed Medicaid for work that was never done. One aide claimed to be working 24 hours a day when in reality she was in North Carolina crooning "Be My Love" to the judges of "American Idol."
At the same time, it is not yet clear whether any patients have been unknowingly endangered or harmed after being cared for by improperly certified workers.
Experts say that until recently, state officials had not paid close attention to home health care fraud. New York only recently became the second state, after Texas, to create a Medicaid inspector-general's office, which primarily focuses on reining in Medicaid fraud.
At the same time, many opine that the incidence of fraud in the home health care system is no greater than that of the medical system at large, and that the complaints are limited to a small portion of agencies and caregivers.
"We're being portrayed negatively when we do a very good job at this every day," says Valerie Collins, the administrator of Village Care Plus, which trains home health care aides and employs about 500 certified aides.
Home health aides and other personal care workers are touted as a lifeline for many older or disabled people. In most cases, they are their only link to the outside world. As an increasing number of family members become too busy or too far-flung to care for their relatives, the aides can become a de facto family, giving companionship to their clients in life and comfort to their relatives after their deaths.
The industry accounts for $1.3 billion of the $35.7 billion spent on Medicaid in New York alone, for the last year. There are more than 140 home care agencies, which are overseen by both the federal and state governments. These are also responsible for supervising patients' care and billing Medicaid.
From recent surveys, the federal government estimates that there are at least 131,000 aides working in New York, though the state does not keep precise figures. Among these are an unknown but growing number of uncertified aides who work outside the Medicaid system.
In between these are more than 1,000 state-licensed contracting agencies that directly employ the workers, train them, and provide their services under contracts to the home care agencies.
According to Cuomo, the types of fraud uncovered so far strongly suggest that problems are widespread in the industry, with aides, contracting agencies and even patients colluding in highly organized schemes.
The investigators discovered that at least two New York City contracting agencies permitted people to buy certificates for $400 or less. These showed that they had been trained as home health aides, despite receiving little or no instruction.
According to Federal rules, home care aides must receive 75 hours of instruction in basic skills like administering medications, taking temperature and blood pressure, bathing and dressing and changing bedpans.
In another scam, dubbed the "50-50 split," companies persuaded patients to hire improperly certified aides, then caused Medicaid to be billed for help they never provided and split the payments with the patients.
In yet other cases, improperly certified aides billed for false work. One submitted bills for 36 hours of work a day, using two contracting agencies. Yet another held a job at a grocery store while claiming he was caring for his ailing father, and submitted hours for days when he was in Tel Aviv.
According to Cuomo's aides, as much as $100 million can be retrieved from fraudulent Medicaid billings.
Cuomo and home care experts opine that this situation has arisen partly at least, because government bureaucracies and laws have not adjusted to an industry that has grown and changed significantly in recent decades.
This growth has been driven by the large numbers of disabled and low-income people who want to spend their final years at home, as well as by government policies intended to encourage home health care as an alternative to more costly hospital and nursing home care. The number of contracting agencies that handle that recruiting and supervision of home care aides has nearly doubled since the early 1990s.
Officials and experts said that these contracting agencies, which are at the center of Mr. Cuomo's inquiry, were not monitored as stringently as the home health agencies. The contracting agencies, for instance, are generally audited less often. And they have little contact with federal regulators, meaning they are subject to one less layer of oversight.
Yet another problem is overlapping state bureaucracies. The Health Department licenses lower-cost programs, which are sponsored by the contracting agencies. The Education Department licenses programs taught at vocational and technical schools. But incidentally, neither maintains a registry of certificates the aides should receive after completing their training.