Medicaid Fraud

Some owners and managers of home health, hospice, home care/private duty agencies, and HME companies mistakenly think that fraud and abuse prohibitions apply only to services paid for by the Medicare Program. In fact, fraud and abuse prohibitions apply to providers if they accept any state or federal funds, including, but not limited to, Medicaid, Medicaid waiver, VA, and Tri-Care. In addition, many private insurers have adopted the prohibitions on fraud implemented by state and federal programs.
 
Private duty home care agencies and home health agencies that provide services to Medicaid and Medicaid waiver patients are increasingly in the crosshairs of fraud enforcers, The reason for enhanced scrutiny is that both the federal government, which partially funds state Medicaid and Medicaid Waiver Programs, and state governments that also fund these programs are alarmed about the high costs of fraud, abuse, and waste.
 
Conventional wisdom says that there are big bucks to be saved if fraud and abuse in the Programs are controlled and ultimately eliminated. Conventional wisdom also says that enforcement actions in Medicaid Programs have just scratched the surface. According to this “wisdom,” there are big bucks to be recouped from “low-hanging fruit!” 
 
A recent report from the Office of Inspector General of the U.S. Department of Health and Human Services seems to support this perception regarding private duty home care agencies based on the following:

• Between 2014 and 2023, at least 34% of fraud convictions in some years were based on private duty home care services. In some years, this percentage was as high as 48%.
• In fiscal year 2023, there were 279 criminal convictions related to private duty home care services compared to 66 for registered nurses and 43 for home health agencies.

Here are some recent examples of “low-hanging fruit” in private duty home care agencies from the 2025 National Healthcare Fraud Takedown, including billing for:

• Services provided while the client was in Jamaica for six months
• Visits cancelled in advance by clients
• Services while the caregiver was on vacation in a foreign country
•  Care provided while the caregiver was working another job

The feds are certainly convinced that Medicaid expenses must be cut and that there is a lot of fraud and abuse in the Medicaid Program. Now is the time for providers to be more vigilant than ever!