The Centers for Medicare and Medicaid Services (CMS) recently imposed a six-month moratorium on new Medicare enrollment for home health and hospice agencies, the latest effort to curb fraud in federal health programs. While targeting fraud, waste, and abuse is a legitimate priority, the government must ensure its oversight is precise, data-informed, and aligned with actual risk levels.
Federal data already highlights where to focus: over 75% of improper Medicaid payments stem from documentation errors, not intentional fraud. This distinction is critical—compliance issues require education, while fraud demands enforcement. Treating both the same leads to poorly calibrated regulations that miss the mark.
Risk isn't uniform across provider types. High fraud concentrations occur in settings with complex billing, high per-beneficiary costs, and limited real-time oversight. In contrast, agency-based home care—where caregivers are W-2 employees—offers transparent, auditable structures with payroll records, tax documentation, and electronic visit verification (EVV) mandated by the 21st Century Cures Act. EVV captures who delivered care, when, and for how long, creating a verifiable record that prevents after-the-fact fabrication.
This model provides a strong accountability framework. However, seven states have yet to fully implement EVV in home care. Before layering on new requirements, CMS should enforce existing tools across all states. Better data sharing between federal and state agencies would also help surface anomalies without duplicative audits that burden providers.
Targeted approaches include using claims data to identify genuine outliers—agencies with unusual billing patterns or geographic footprints—and proactive provider education on documentation standards to reduce errors upfront. As GOP infighting threatens broader healthcare policy efforts, such precision becomes even more vital.
The home care industry, represented by the Home Care Association of America, argues that program integrity should be proportionate to risk and grounded in evidence. CMS has stated its goal is shifting from 'pay-and-chase' to real-time detection. The infrastructure already exists; what's needed is the commitment to use it wisely.
Missteps could harm access. For instance, political claims about fraud can complicate reform efforts. Policymakers must build on existing accountability systems rather than resorting to blunt instruments that penalize compliant providers and new market entrants.
The data points the way. The tools are in place. The opportunity now is to focus enforcement where the evidence shows the greatest risk—and avoid undermining a system that already works for millions of Americans.
