Frauds in HealthCare, MediCare and Medicaid

1/ Medicare, Home Care... and Frauds https://smpresource.org/medicare-fraud/fraud-schemes/home-health-care-fraud/ Medicare Parts A and B cover intermittent or short-term home health services. These services must be provided by a Medicare-approved home health agency that works with your doctor to manage your care. To be eligible for Medicare coverage: • Your doctor must determine it’s medically necessary for you to receive skilled care services at home. Skilled care services at home could include part-time or “intermittent” nurse and nurse aide visits (personal, hands-on care) and rehabilitation services, which include speech-language pathology, physical and occupational therapy, and medical social services. • Your condition must be expected to improve in a reasonable amount of time or your condition requires skilled therapy to maintain your current condition or prevent or slow, further deterioration. • You must be considered “homebound.” This means you are unable to leave your home without assistance, it requires considerable and major effort, or it is considered dangerous due to your current health condition. You may leave home for medical care and some short or infrequent outings (for example, worship services) as long as you meet these conditions. o Note: Even if you do not qualify for home health services, you may still be eligible to receive outpatient therapy services in a doctor’s office, outpatient hospital setting, rehabilitation agency, Comprehensive Outpatient Rehabilitation Facility (CORF), public health agency, or your home. Outpatient therapy services are covered by Medicare Part B and subject to the 20% copayment. Report potential home health care fraud, errors, or abuse if: • You see on your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB) charges for: o Home health services when you did not meet Medicare’s “homebound” criteria o Services that were not deemed medically necessary by your doctor o Home health services like skilled nursing care and/or therapy services that were not provided • You were: o Enrolled in home health services by a doctor you do not know o Offered things such as “free” groceries or a “free” ride from a home health agency in exchange for your Medicare number or to switch to a different home health agency o Charged a copayment for home health services o Asked to sign forms verifying that home health services were provided even though you did not receive any services • Someone came to your home and provided housekeeping or medication services, but you see on your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB) that Medicare was billed for a covered service like skilled nursing or other therapy instead. • You accept cash or gifts in exchange for going along with a home health scam. To learn more about tips related to home health care fraud, click here. To learn how to read your Medicare Summary Notice (MSN) and Explanation of Benefits (EOB), click here. Report Suspected Fraud To report suspected fraud, click here. Report Suspected Medicare Fraud SMP Resources • Home Health Care Fraud Tip Sheet (English) (Arabic) (Chinese Simplified) (French) (German) (Korean) (Russian) (Spanish) (Tagalog) (Vietnamese) • Home Health Care Fraud Infographic (English) (Arabic) (Chinese Simplified) (French) (German) (Korean) (Russian) (Spanish) (Tagalog) (Vietnamese) • Home Health Care Fraud Video 2/ https://www.npr.org/sections/health-shots/2020/01/21/789958067/patients-want-to-die-at-home-but-home-hospice-care-can-be-tough-on-families ...Usually, hospice care is offered in the home, or sometimes in a nursing home. Since the mid-1990s, Medicare has allowed the hospice benefit to cover more types of diagnoses, and therefore more people. As acceptance grows among physicians and patients, the numbers continue to balloon — from 1.27 million patients in 2012 to 1.49 million in 2017. According to the National Hospice and Palliative Care Association, hospice is now a $19 billion industry, almost entirely funded by taxpayers. But as the business has grown, so has the burden on families, who are often the ones providing most of the care. For example, one intimate task in particular changed Joy Johnston's view of what hospice really means — trying to get her mom's bowels moving. Constipation plagues many dying patients. "It's ironically called the 'comfort care kit' that you get with home hospice. They include suppositories, and so I had to do that," she says. "That was the lowest point. And I'm sure it was the lowest point for my mother as well. And it didn't work." Hospice agencies primarily serve in an advisory role and from a distance, even in the final, intense days when family caregivers, or home nurses they've hired, must continually adjust morphine doses or deal with typical end-of-life symptoms, such as bleeding or breathing trouble. Those decisive moments can be scary for the family, says Dr. Joan Teno, a physician and leading hospice researcher at Oregon Health and Science University. How To Be A Better Caregiver When A Loved One Gets Sick "Imagine if you're the caregiver, and that you're in the house," Teno says. "It's in the middle of the night, 2 o'clock in the morning, and all of a sudden, your family member has a grand mal seizure." That's exactly what happened with Teno's mother. "While it was difficult for me to witness, I knew what to do," she says. In contrast, Teno says, in her father's final hours, he was admitted to a hospice residence. Such residences often resemble a nursing home, with private rooms where family and friends can come and go and with round-the-clock medical attention just down the hall. Teno called the residence experience of hospice a "godsend." But an inpatient facility is rarely an option, she says. Patients have to be in bad shape for Medicare to pay the higher inpatient rate that hospice residences charge. And by the time such patients reach their final days, it's often too much trouble for them and the family to move. HHS Inspector General Finds Serious Flaws In 20% Of U.S. Hospice Programs Hospice care is a lucrative business. It is now the most profitable type of health care service that Medicare pays for. According to Medicare data, for-profit hospice agencies now outnumber the nonprofits that pioneered the service in the 1970s. But agencies that need to generate profits for investors aren't building dedicated hospice units or residences, in general, mostly because such facilities aren't profitable enough. Joe Shega, chief medical officer at for-profit Vitas, the largest hospice company in the U.S., insists it's the patients' wishes, not a corporate desire to make more money, that drives his firm's business model. "Our focus is on what patients want, and 85 to 90 percent want to be at home," Shega says. "So, our focus is building programs that help them be there." For many families, making hospice work at home means hiring extra help.... This experience of family caregivers is typical, but often unexpected. 'It's a burden I lovingly did' "It does take a toll" on families, says Katherine Ornstein, an associate professor of geriatrics and palliative medicine at Mount Sinai Hospital in New York, who studies what typically happens in the last years of patients' lives. The increasing burden on loved ones — especially spouses — is reaching a breaking point for many people, her research shows. This particular type of stress has even been given a name: caregiver syndrome. "Our long-term-care system in this country is really using families — unpaid family members," she says. "That's our situation." A few high-profile advocates have even started questioning whether hospice is right for everybody. For some who have gone through home hospice with a loved one, the difficult experience has led them to choose otherwise for themselves. Social worker Coneigh Sea has a portrait of her husband that sits in the entryway of her home in Murfreesboro, Tenn. He died of prostate cancer in their bedroom in 1993. Coneigh Sea is a social worker from Murfreesboro, Tenn., who cared for her husband as he died on home hospice. Now, she wants to make sure her children don't do the same for her. Blake Farmer/WPLN Enough time has passed since then that the mental fog she experienced while managing his medication and bodily fluids — mostly by herself — has cleared, she says. But it was a burden. "For me to say that — there's that guilt," she says, then adds, "but I know better. It was a burden that I lovingly did." She doesn't regret the experience but says it is not one she wishes for her own grown children. She recently sat them down, she says, to make sure they handle her death differently. "I told my family, if there is such a thing, I will come back and I will haunt you," she says with a laugh. "Don't you do that." Sea's family may have limited options. Sidestepping home hospice typically means paying for a pricey nursing home or passing away with the cost and potential chaos of a hospital — which is precisely what hospice care was set up to avoid. As researchers in the field look to the future, they are calling for more palliative care, not less — even as they also advocate for more support of the spouses, family members and friends who are tasked with caring for the patient. "We really have to expand — in general — our approach to supporting caregivers," Ornstein says, noting that some countries outside the U.S. pay for a wider range and longer duration of home health services. "I think what we really need to do is be broadening the support that individuals and families can have as they're caring for individuals throughout the course of serious illness," Ornstein says. "And I think that probably speaks to the expansion of palliative care in general." Blake Farmer's reporting on end-of-life care is part of a reporting fellowship on health care performance, sponsored by the Association of Health Care Journalists and supported by the Commonwealth Fund. 3/ https://www.kff.org/medicaid/understanding-medicaid-home-care-amid-cms-focus-on-potential-fraud-and-abuse/ Understanding Medicaid Home Care Amid CMS Focus on Potential Fraud and Abuse Authors: Alice Burns, Abby Wolk, and Robin Rudowitz Published: Feb 24, 2026 PrintEmailCopy LinkAdd KFF on Google Potential fraud in state Medicaid programs is getting renewed attention, with a recent emphasis on home care, also known as personal care or in-home supportive services. Home care helps with self-care activities such as bathing, dressing, and eating for older adults and people with disabilities. KFF estimates that over 5 million people use Medicaid home care, which allows individuals to receive long-term care without moving into an institution. The Trump administration has recently pointed to Medicaid home care as a source of fraud. Medicaid home care is susceptible to fraud because services are provided in people’s homes to vulnerable individuals who may be less able to advocate for themselves, including some with Alzheimer’s and other dementias. However, there are also additional safeguards against fraud in Medicaid home care compared to other types of Medicaid services. This issue brief describes how Medicaid home care operates, including who is eligible, the various systems in place to promote program integrity in its delivery, and challenges using data newly released by the Centers for Medicare and Medicaid Services (CMS). Key takeaways include the following. • All states provide optional home care services to people whose needs are sufficient to warrant institutionalization. An institutional level of care is generally beyond what family members are capable of providing. • Recognizing the higher risk of fraud in Medicaid home care, federal and state governments have implemented additional tools to identify and detect home care fraud. States, along with the federal government, use provider credentialing and enrollment and data analytics to help prevent fraud. There has been new attention on fraud in Minnesota’s Medicaid program recently, but the fraud, and the state’s work to root it out, date back at least 18 months. • On February 14, 2026, CMS released a dataset with provider-level spending data that the agency suggests could be used to identify unusual billing patterns for specific services, states, or providers, but the limited data could result in mistaken conclusions. Home care is a major emphasis of the new dataset, which stems from the fact that second to hospital spending, long-term care is the second-largest source of Medicaid spending. Although Medicaid long-term care was historically provided primarily in nursing facilities, most enrollees who use long-term care now receive home care. Why does Medicaid cover home care and who is eligible for services? All states provide optional home care services. Under Medicaid, states are required to cover long-term care provided in nursing facilities, but not home care, which has been referred to as the “institutional bias” in Medicaid. States may only provide home care if they can demonstrate that providing the services would cost no more than institutional care would cost for an individual. All states choose to provide optional home care to people who would otherwise require institutionalization. The increased availability of home care reflects people’s preferences to remain in their homes. Expansions of Medicaid home care services also followed the 1999 Supreme Court ruling in Olmstead v. L.C., which declared that unjustified institutionalization of people with disabilities by a public entity (including Medicaid) is a form of discrimination and not permissible under the 1990 Americans with Disabilities Act. Even though nearly all of the benefits are optional for states to provide, the majority of people who use long-term care now do so at home. Medicaid home care use is limited by eligibility criteria that generally make it only available to people whose needs are sufficient to warrant institutionalization. To be eligible for Medicaid home care, applicants must meet both financial and “functional” eligibility criteria. Functional eligibility for Medicaid home care, which is evaluated by assessment tools developed by states, generally requires individuals to demonstrate that they need an institutional level of care. There are no recent data available about states’ specific definitions for an institutional level of care, but it generally indicates that people would require 24-hour services and assistance with multiple activities of daily living (ADLs), which include bathing, dressing, eating, toileting, continence, and transferring between bed and other settings. An institutional level of care is generally beyond what family members are capable of providing. People who require an institutional level of care generally have complex needs that require both skilled and unskilled services and often require services to be provided around the clock. In some cases, family caregivers may not have the medical expertise to provide services, but there are also challenges related to the physical demands of the job and having time to provide such intensive services. Helping family members to bathe, dress, and toilet themselves often requires the strength to lift them, which not all family members have. The time required to provide such intensive services also makes it difficult for family caregivers to provide this level of care and maintain employment or take care of their own health needs. KFF’s focus groups with paid and unpaid family caregivers provide detail that caregiving is physically, mentally, and emotionally challenging; and that family caregivers cannot provide an institutional level of care without supports. To help people requiring an institutional level of care remain at home, Medicaid supports family caregivers by providing supplemental paid care and with direct supports, such as respite care, training, and in some cases payments to the family caregivers to reflect the fact that caregiving makes it impossible to maintain outside employment. What program integrity tools for Medicaid home care exist? Recognizing the higher risk of fraud in Medicaid home care, federal and state governments have implemented additional tools to identify and detect home care fraud. In 2016, Congress passed the 21st Century Cures Act, which requires states to implement electronic visit verification for all Medicaid personal care and home health services if a visit is made to a person in the home. State’s electronic visit verification must include six data elements: member receiving the services, caregiver providing the service, type of service, location of the service delivery, date of the service, and time the service begins and ends. Electronic visit verification was established to help promote fiscal integrity for Medicaid home care, and states had until 2023 to fully implement the requirements. The Health and Human Services Office of Inspector General (HHS OIG) has an active project underway to evaluate the availability and completeness of the electronic visit verification data and how states are using the data to promote program integrity. An HHS OIG report finds that in fiscal year 2024, there were 298 fraud convictions....