The US home healthcare market is projected to reach $173 billion by 2026 — outpacing growth in all other care types. However, with millions of caregiver visits and the recent COVID-related changes to state and federal guidelines, the potential for fraud, waste, and abuse in homecare is especially difficult to manage. In fact, the fiscal year 2019 national Medicaid improper payment rate estimate was 14.9%, representing $57.36 billion.

How can state Medicaid agencies and contracted managed care organizations (MCOs) successfully prevent improper payments as the homecare industry continues to grow? Here are six ways to approach fraud, waste, and abuse proactively.

1. Block enrollment of unscrupulous homecare providers

One of the most important preventive measures against dishonest billing is criminal background checks. The Medicare Provider Enrollment, Chain, and Ownership System (PECOS) gives state Medicaid agencies a helpful tool for weeding out potential fraudsters. However, not all providers are in PECOS, and this database doesn’t automatically update with new information about criminal activity. In short, vulnerabilities remain.

To better defend against bad actors, the Medicaid Integrity Institute (MII) recommends a comprehensive fingerprint-based criminal background check program for homecare providers. In addition, a Rap Back service can promptly detect any new criminal offenses that occur after the initial screening.

Another strategy is to incorporate business information provided by an objective third party. Additional data can either corroborate what businesses provide or flag their self-reported information for review. An example is Dun & Bradstreet’s Healthcare Provider Risk Index, a proprietary risk-scoring system that ranks providers’ potential to demonstrate characteristics consistent with known instances of fraud, waste, and abuse.

2. Require stringent caregiver screening

Caregivers spend extended periods of time alone with members at home, usually without direct supervision. This scenario creates a greater risk of falsified assessments or timesheets to obtain improper payments. This can occur with or without the provider’s knowledge. Therefore, it’s critical that caregivers be thoroughly vetted through criminal background checks and monitored through a Rap Back service in the same way homecare providers are.

In addition, MII recommends implementing a statewide caregiver registry with unique identifiers to track screening results and any confirmed offenses, even if they wouldn’t appear on a criminal background report. This will ensure that caregivers with questionable prior actions aren’t able to move from agency to agency.

3. Confirm assessments are appropriate

To ensure that members aren’t receiving unnecessary services (whether deliberately or not), payers may want to require that assessments be conducted face-to-face by qualified independent agents using validated assessment tools. Another strategy is to provide education for members and their families to spot and report suspected fraud or abuse by their provider.

4. Clarify provider responsibilities and noncompliance penalties

Improper payments can inadvertently occur when the provider doesn’t understand State Medicaid plan and waiver rules. State Medicaid agencies and MCOs should implement substantive training programs for staff in all roles – owners, managers, and caregivers – and a documented, required schedule for refresher courses.

Rather than creating your own materials, the Medicaid Integrity Program has a comprehensive toolkit for homecare providers. It’s written in clear language with examples to ensure comprehension and improve compliance. Humana also has an excellent ethics policy document to review for best practices.

Make sure your training includes signatures attesting to attendance, responsibility for content, and acknowledgement of noncompliance penalties. By maintaining accurate training records along with attestations, you can counter future legal defense arguments that noncompliance was due to ignorance or administrative error.

5. Optimize claims review to prevent improper payments

Payers often struggle to process claims due to incorrect billing codes and discrepancies with claims data or unauthorized hours. The implementation of Electronic Visit Verification (EVV) earlier this year will reduce the likelihood for error and fraud by accurately identifying the member, recording the caregiver’s location and clock-in and clock-out times, and services provided. Interfacing your Medicaid Management Information System (MMIS) with EVV systems would enable automatic cross-checks of billed claims against submitted timesheets for any discrepancies.

6. Use machine learning and AI to predict improper payments

Program integrity risks have become increasingly difficult to recognize in light of today’s integrated providers and value-based payment models. Following the lead of CMS, payers should look for ways to shift from “pay and chase” to a fraud prevention approach powered by machine learning and artificial intelligence (AI). With sufficient details on claims, paired with databases containing accurate provider and beneficiary information, analysts can develop algorithms to detect patterns indicating potential overpayments or larger schemes involving multiple providers.

With the HHAeXchange Payer Platform, you get a unified, real-time approach to payer management. Claims cannot pass beyond HHAeXchange unless the service rendered reconciles with the authorization, contract, plan of care, and the electronic verification of the visit. Plus, our reporting and analytics dashboards provide an additional layer of visibility for enhanced compliance.


As you can see, Medicaid fraud, waste, and abuse in homecare isn’t inevitable. By implementing a combination of screening, education, and technology, payers can both improve member care and preserve limited Medicaid funds. Learn more about how the HHAeXchange Payer Platform can prevent improper payments to your provider network.