Overview

Older Americans overwhelmingly want to age in place, and federal policy increasingly aims to support that goal. However, the home-based Medicare and Medicaid benefits designed to keep seniors independent have become the highest-margin targets for organized fraud in the federal health care system. The President has promised to protect seniors’ independence, which means protecting these benefits from the criminal enterprises that have exploited these benefits and the beneficiaries that rely on them.

Aging in America

Older Americans, meaning Americans over the age of 65, make up around 1 in 5 people in America (FRED, 2024); it is the oldest the American population has ever been. In 1920, people 65 and older were about 4.7% of the population (1 in 20), while in 2020, this number grew to 16.8% of the population (Caplan, 2023). Between 2024 and 2030, the last Baby Boomers will reach Medicare eligibility. By 2030, when the youngest Boomers turn 65, the U.S. Census Bureau projects that 20% of the total U.S. population will be 65 or older, which is roughly 67 million Medicare beneficiaries (U.S. Census Bureau, 2020). From 2010 to 2030, the population of Americans aged 65 and older will have grown from 39.7 million to an estimated 67 million, a 69% increase in two decades. By comparison, this generation is sicker than those who came before them: an estimated 40% of Medicare beneficiaries, by 2030, will carry three or more chronic conditions, up from 26% in 2010, and the prevalence of diabetes, heart disease, and obesity-related conditions is expected to increase (Gaudette et al., 2015). This has translated into increased Medicare costs and is projected to grow to $1.8 trillion by 2031.

In addition to Medicare spending on seniors, Medicaid is often used to finance seniors’ health care. Medicaid covers Medicare premiums and cost-sharing for low-income Medicare beneficiaries. It will often finance long-term care that Medicare does not cover (e.g., when a senior “spends down” to receive Medicaid support for nursing home care). Sadly, this happens often: for people who enter a nursing home as private‑pay or Medicare‑only, roughly 1 in 6 will convert to Medicaid over the course of a typical stay, and a majority will do so if they remain in care for several years (Carroll, 2025).

Unsurprisingly, older Americans also see the fastest increase in personal health spending, including spending on hospice and home care services. According to the Centers for Medicare & Medicaid Services (CMS), older Americans spent $1.2 trillion on health care, or $22,356 per person, compared to working-age adults (~$9,000 per person) and children (~$4,000 per person). This population also saw the fastest spending growth, compared to other populations, increasing from 2.6% between 2016 and 2018 to 4.5% from 2018 to 2020 (HHS, 2023).

Older Americans are also absorbing greater shares of spending. In 2022, Medicare beneficiaries spent an average of $6,330 out of pocket on health care costs, including Medicare premiums (up from $5,460 in 2016) (Ochieng et al., 2025; Cubanski et al., 2019). To put this into perspective, out-of-pocket spending accounted for 39% of Medicare beneficiaries’ average Social Security income and 11% of their average total per capita income; however, 1 in 4 beneficiaries paid 21% of income on out-of-pocket costs and 1 in 10 paid more than 39% (Ochieng et al., 2025; Cubanski et al., 2019). By comparison, working-age adults spent roughly one-third as much per capita on health care ($9,000 vs. $22,356), and the share of income consumed by out-of-pocket costs is far lower for working households (HHS, 2023).

Like President Trump said, “…these [Social Security and Medicare] programs are promises to our Seniors, ensuring they can live their golden years with dignity…” (Republican National Committee, 2024). There is an urgency to alleviate cost pressures on seniors and taxpayers, as well as space and workforce constraints on facilities. As a result, the U.S. government has authorized a variety of flexible benefits, including Medicaid Home-and-Community-Based Services (HCBS) waivers, home health demonstrations, paid caregivers, and other programs. Unfortunately, these are also the most lucrative benefits for criminal enterprises to target. When fraud inflates Medicare and Medicaid program costs, the increases in cost-sharing and premiums fall on a population that relies on a fixed income. This cost-shifting steals from older Americans. It is not a white-collar crime. Every dollar stolen from Medicare raises the cost to beneficiaries through increases in Part B premiums, by depleting the Hospital Trust Fund (as insolvency is now projected for the mid-2030s), and changing the Medicare Advantage benchmarks that follow fee-for-service (FFS) spending. Protecting seniors (and their health benefits) from fraud is the same policy as protecting seniors from rising premiums and greater out-of-pocket expenses, and fraudsters are increasing costs for seniors.

Protecting Seniors’ Independence

Two-thirds of adults aged 60 to 79 want to stay in their current home even if they can no longer properly care for themselves or must depend on others. About a quarter of those would choose to stay even if they cannot adequately care for themselves, underscoring how strongly they prioritize aging in place (Linus, 2026). President Trump, in his 2024 Campaign Platform, recognized this and promised to protect seniors’ ability to stay in their home longer, saying “Republicans will protect these vital programs and ensure Economic Stability. We will work with our Great Seniors, in order to allow them to be active and healthy. We commit to safeguarding the future for our Seniors and all American families…” (Republican National Committee, 2024). The President’s commitment to giving Medicare beneficiaries excellent care, while combatting waste, fraud, and abuse, is consistent with the roots of the Medicare program.

When Congress established Medicare and Medicaid in 1965, home health services were included as part of the original statute, recognizing that hospital and nursing home care were not only more expensive but also less preferred by patients. Policymakers have continued to build from the original intent of home health, including more targeted programs for the aging and disabled population; however, these programs have become targets for organized fraud (HHS, 2024d).

Criminals are Stealing Care & Money from American Seniors

When the notorious American bank robber Willie Sutton was asked why he robs banks, he responded, “Because that’s where the money is.” As its history has shown, the same goes for the current American safety net system; organized crime sees that this is where the money is and steals from American seniors and taxpayers alike.

As a result, Medicare hospice spending increased from $23.7 billion in 2022 to $28.3 billion in 2024, while Medicare FFS home health spending increased from $15.9 billion in 2023 to $16.0 billion in 2024 (MedPAC, 2026). MedPAC reported that 1.82 million Medicare beneficiaries used hospice in 2024 and that 2.7 million FFS Medicare beneficiaries received home health services in 2024 (MedPAC, 2026).

The scope of the fraud is hard to measure. One way that Medicare tracks this is through the number and rate of improper payments.[1] In FY25, CMS estimated $28.83 billion in improper Medicare FFS

payments, $23.67 billion in improper Medicare Advantage payments, $4.23 billion in improper Part D payments, $37.39 billion in improper Medicaid payments, and $1.37 billion in improper Children’s Health Insurance Program (CHIP) payments (HHS, 2026b). Specifically, in home health, CMS reported an improper payment error rate of 7.7% (~ $1.2 billion), and the House Energy & Commerce Committee cited HHS’s Office of Inspector General (OIG) reporting of $198.1 million in suspected hospice fraud in FY23 (U.S. House of Representatives Committee on Energy and Commerce, 2026).

These improper payment estimates likely understate criminal fraud. CMS’s Comprehensive Error Rate Testing (CERT) relies on heavy documentation to measure improper payments (HHS, 2026c). It audits whether claims have proper paperwork, and it does not measure whether the underlying services were medically necessary, actually delivered, or billed under stolen beneficiary identities. It is hard to know whether a provider mistakenly forgot paperwork or whether intentional fraud has occurred. For example, phantom patients, identity theft via Covered California, “straw” owners cycling through new billing numbers, and beneficiaries who never knew they had been enrolled, are largely invisible to the methodology. Therefore, it is likely that the $1.2 billion home health figure is a floor, not a ceiling.

The Home Health Benefit

The Medicare home health benefit was established for seniors under Title XVIII as part of the Social Security Act Amendments in 1965 (Social Security Act Amendments, 1965). The design drew upon the Montefiore Home Care Program, launched by Montefiore Hospital in January 1947 under Dr. Martin Cherkasky. Cherkasky noted that patients could get better care in their homes, including medical service, social services, nursing, physical therapy, and even housekeeping, at lower cost than providing those services in the hospital—$3 a day versus $12 a day (Cherkasky, 1949). He declared it was a patients-first benefit, writing, “We have salvaged a human being, and this by individualizing her care and by coordinating all the facilities of the hospital and community in their joint fight for health and against disease” (Cherkasky, 1949).

As Congress deliberated over the creation of hospital insurance, staff at the Social Security Administration (SSA) and the Department of Health, Education, and Welfare (HEW) compiled analyses of what should be included in the proposed hospital insurance benefit, including home health (U.S. Department of Health, Education, and Welfare, 1959). The Montefiore model was suggested to be too broad, so Agnes W. Brewster, an officer in the Office of the Commissioner, turned to 79 Blue Cross plans to understand how to operationalize home health (Brewster & Bloodgood, 1959). Similar analyses by the American Enterprise Association and members of the Public Health Service were concerned about how to promote home health without increasing error and overutilization (American Enterprise Association, 1962; Kurlander, 1954).

The resulting design, as reflected in the King-Anderson health insurance model, was intentionally limited (U.S. House of Representatives [USHR], 1965). Beneficiaries had to have a prior three-day hospital stay, and coverage was capped at 100 visits per year. The benefit covered part-time skilled nursing care, physical and speech therapy, home health aide services, and medical social services and had to be delivered by a Medicare-certified home health agency (HHA). These constraints prevented billing for visits that had not been ordered, continuing visits after they were no longer medically necessary, duplicate services from several community agencies, charging hospital-level costs for less intensive home services, and inconsistent classification of nursing, housekeeping, rehabilitation, and social services (Kurlander, 1954).

The creation of the new benefit created a new opportunity for criminal enterprise. The U.S. Senate’s Special Committee on Aging held a series of hearings entitled “Medicare and Medicaid Frauds.” Parts 8 and 9 of these hearings focused on home health agencies, particularly the newly created home health agencies as part of the Social Security Act. A central case examined was Home Kare, Inc., a licensed health care agency in California, along with its subsidiaries (U.S. Senate Special Committee on Aging, 1976). Home Kare was accused of manipulation of financial records, double billing of Medicare cases, misuse of funds for personal purposes, and exploitation of preferential treatment arrangements with insurance companies. They pled the Fifth for their criminal activity. As a result, Congress passed the Medicare-Medicaid Anti-Fraud and Abuse Amendments of 1977 (P.L. 95-142), strengthening criminal penalties, instituting anti-kickback provisions, requiring ownership disclosures, suspending convicted practitioners, creating State Medicaid Fraud Control Units (MFCUs), establishing cost-reporting structures, and strengthening claims payment review procedures (Medicare-Medicaid Anti-Fraud and Abuse Amendments, 1977). Criminals were already stealing healthcare dollars away from American seniors.

Despite the fraud and abuse investigations that raised concerns about overutilization and improper practices, Congress sought to expand the benefit. Many Congressional leaders recognized that the original restrictions excluded beneficiaries who could safely and more cheaply be treated at home and amended the benefit, and cited a study by the Assistant Secretary for Planning & Evaluation (ASPE) to show that utilization was far below the 100-visit ceiling (HEW, 1984). In 1980, Congress passed the Omnibus Reconciliation Act, eliminating the prior hospitalization requirement, the copayment for home health under Part B, and the 100-visit limit (Omnibus Reconciliation Act, 1980). The benefit was expanded again in 1988 after the courts found that Medicare's interpretation of “part-time or intermittent” was too narrow, which broadened access for eligible beneficiaries (Duggan v. Bowen, 1988 ).

These two changes exploded the benefit, due to the deterioration of program controls, which allowed waste, fraud, and abuse to grow within the program (GAO, 1996). Spending grew from roughly $2.6-2.7 billion in 1989 to $12.7 billion in 1994 and about $17-18 billion by 1996–97. In their review of the program, the GAO and the HHS-OIG found that 25-40% of sampled home health services did not meet Medicare requirements (i.e., patients were not homebound, services were not medically necessary, visits were never provided, or poor documentation) (HHS, 1997a). In addition, problem providers drove a disproportionate share of spending; for example, the report found that roughly one quarter of agencies were classified as “problem providers” and accounted for close to 45% of home health spending in states audited (GAO, 1996). The pattern was already clear: organized fraud, not isolated billing errors, was driving a substantial share of program costs.

In response to the rampant abuse, Congress passed the Balanced Budget Act of 1997 (P.L. 105-33), creating new payment rules in an attempt to corral the criminal behavior. As of October 1, 1997, under the new Interim Payment System, a home health agency would receive the lowest of its actual reasonable costs, a per-visit payment limit, or an aggregate per-beneficiary limit based on the agency’s 1994 costs (Balanced Budget Act, 1997). Home health agencies were required to be bonded (a requirement that was never fully implemented), could face even harsher civil monetary penalties, and even put a temporary moratorium on the registration of new home health agencies (Balanced Budget Act, 1997). Additional measures, like the creation of the Home Health Prospective Payment System, as well as the continued Operation Restore Trust, led to a drop in health spending from its peak of $18.3 billion in 1997 to $9.5 billion in 1999 (GAO, 2000; HHS, 2003). Experts found that despite changes in the home health payment system, patients were still getting the care they needed: no increase in hospital readmissions, virtually no change in the speed of home health placement, no substantive change in 90-day mortality, and even modest improvement in some health outcomes (HHS, 1999; Huckfeldt et al., 2014; Kilgore et al., 2009; Schlenker et al., 2005).

Congress made further changes to home health in the 2000s and 2010s, requiring a face-to-face encounter, uncapping visit limits, and created the Patient-Driven Groupings Model (PDGM) (Bipartisan Budget Act, 2018). Today, beneficiaries can get home health with no visit cap and no copayment. It is no surprise that criminal enterprises have chosen to continue to exploit this benefit for American seniors (MedPAC, 2026).

The Hospice Benefit

Similar to the home health benefit, there was a growing body of evidence that showed that the final months of life were often spent in high-cost settings, particularly hospitals (U.S. Senate Special Committee on Aging, 1972). End-of-life-care, or palliative care, was often provided as a community-based, non-profit, volunteer-intensive effort focused primarily on cancer patients. Hospice care focused on enabling patients to remain at home (HHS, 2000). In 1979, GAO identified just 59 operational organizations that considered themselves hospices, primarily provided through nonprofit and volunteer organizations (GAO, 1979; GAO, 1989). These were often funded through private donations, philanthropy, foundation grants, volunteer labor, and limited demonstration projects. For instance, after the National Cancer Act of 1971, the National Cancer Institute had the authorization to allocate funds to limited demonstrations and grants, one of which was funding hospice care for those terminally ill (National Cancer Act, 1971; National Cancer Act Amendments, 1974).

HEW reported on the limited activities of hospice, finding it a lower-cost setting that can better serve patients in their end-of-life. Private insurers and hospitals alike were beginning hospice programs to support patients, and HEW concluded that, “the hospice movement as a concept for caring for the terminally ill and their families is a viable concept and one which holds out a mean of providing more human care for the Americans dying of terminal illness while possibly reducing costs” (HEW, 1978). Yet, the report, drafted in the midst of the first major fraud investigations of the Medicare program, gave a stark warning: “The Task Force is acutely aware of the need to build into any system of Federal support a substantial oversight and monitoring component, not only to assure that the financial interests of the Federal government have been protected, but also to assure that the public is directly protected against the charlatan. This latter element is especially important since hospice programs are dealing with individuals in emotionally charged situations when they are most vulnerable to exploitation” (HEW, 1978). The Department knew that the hospice benefit would be a “most fertile environment” for fraud to take place (HEW, 1978).

As a response, Congress passed the Tax Equity and Fiscal Responsibility Act (TEFRA) in 1982, creating the Medicare hospice benefit (TEFRA, 1982). The law required physicians to certify a beneficiary’s terminal illness, and the patient had to elect into the benefit itself. Payments to hospice providers were aggregate, and on an prospective per diem payment structure. And finally, the benefit expired in 1986 (TEFRA, 1982).

The benefit worked for patients: it took care of patients, mostly with terminal cancer diagnoses. Patients stayed for ~30 days, and all but 5% died while in hospice care. Care was primarily delivered at home. The National Hospice Study found that hospice delivered the same level of quality care, while allowing loved ones to die at home—something still important to families for their loved ones (Greer et al., 1986; Mor & Kidder, 1985). Congress made the benefit permanent in 1986 and expanded it to allow patients in nursing homes to receive the benefit as well as allow states to add a hospice benefit to their Medicaid programs (Consolidated Omnibus Budget Reconciliation Act of 1985, 1986).

The expansion into nursing facilities was, in fact, a “fertile environment” for fraud. During Operation Restore Trust, the HHS-OIG found that patients enrolled in hospice care often had no terminal diagnosis, and the majority of those with no terminal diagnosis (60%) were in a nursing facility rather than at home (HHS, 1997b; HHS, 1997c). Patients in nursing homes getting hospice care didn’t get the same attention as if they were able to receive hospice at home (HHS, 1997b; HHS, 1997c; HHS, 1997d). And, in March of 1998, the HHS-OIG issued a special fraud alert for nursing homes, citing them for extensive kickback schemes which ultimately hurt patients (HHS, 1998).

Congress made limited reforms amid the fraud investigation, requiring more physician recertification but also allowing unlimited number of 60-day periods of hospice (Balanced Budget Act, 1997). Hospice spending more than tripled between 2000 and 2007 (from $2.9 billion to $10 billion), hospice users doubled, and the average length of stay increased by 50% (MedPAC, 2008; MedPAC, 2009). By 2009, MedPAC flagged their concerns with the rate of growth in the hospice program (MedPAC, 2008; MedPAC, 2009).

The rapid expansion has continued since. Between 2009 and 2011, HHS-OIG repeatedly flagged that patients were enrolled in the hospice benefit who were not terminally ill but instead were listed as having multiple chronic conditions (e.g., dementia, diabetes, heart disease) (HHS, 2009a; HHS, 2009b; HHS, 2011). Patients continued to outlive their terminal illnesses, with the HHS-OIG continuing to flag longer average stays and lower service intensity over the next decade (HHS, 2018b). And the criminal fraud showed in poorer patient care: minimal to no visits to patients in hospice, unmanaged pain, failed basic care planning (HHS, 2018b). Reforms, like face-to-face encounter requirements, the Hospice Quality Reporting Program (HQRP), surveys, payment bumps, and some limited program-integrity tools, barely moved the needle to stop the patient abuse and rampant criminal fraud (Consolidated Appropriations Act, 2020; HHS, 2015a; IMPACT Act, 2014; Patient Protection and Affordable Care Act, 2010). For example, the hospice systems in LA County have a surprisingly high hospice survival rate, continuing the decades-long trend in hospice care (MedPAC, 2025).

Long Term Services and Supports (LTSS)

While Medicare covers skilled, medically necessary home care, as well as hospice care, it does not cover long-term personal assistance, like bathing, dressing, meals, and mobility. Medicaid, under Title XIX of the Social Security Act, required states to cover these services in an inpatient setting; meaning, seniors were only able to get access to some of these services if they would consent to getting care in a nursing home (rather than at a community facility or at home) (Social Security Amendments, 1965).

At the same time, the number of nursing homes in the United States more than doubled, from 9,600 to 23,000. Nursing home beds more than tripled, from 331,000 to 1.1 million (Congressional Research Service, 2023). This was in part because of new laws that allowed states to cover medical expenses for the elderly poor, including nursing home care, and finance it through an open-ended federal match (Social Security Amendments, 1960). The newly created Medicaid program, in 1965, made skilled nursing facilities for the elderly poor a mandatory benefit and removed guardrails that slowed program growth under Kerr-Mills, virtually underwriting all nursing home care in America (Social Security Amendments, 1965).

In just ten years, Medicaid had become the dominant payer for long-term institutional care (KFF, 2015). The program’s spending was out of control and poorly serving patients: between 1960 and 1973, nursing home expenditures rose by 1,400%, and Medicaid was the dominant payer, leading the Senate Aging Committee to declare it a “failure in public policy” (Aging, 1974). While the explosive growth in the program was largely attributed to volume, the Committee documented extensive fraud, abuse, and financial irregularities that were leading to patient harm (Aging, 1974; Aging, 1975). For example, the Committee found theft and misuse of patients’ personal funds, payroll padding, fictitious or unnecessary billing, as well as weak state and federal auditing and enforcement that allowed these practices to continue (Aging, 1975). Criminal enterprise had gotten to be so bad that the Committee called out “Medicaid mills,” which were facilities in New York, Newark, Passaic, Paterson, Chicago, Detroit, Los Angeles, and Oakland that took in a fifth of the federal Medicaid expenditures. According to the report, roughly two-thirds of that amount was diverted to criminal waste, fraud, and abuse (Aging, 1976b). These Medicaid mills were connected to organized crime, with doctors and clinic operators being extorted by crime bosses. In one instance, a physician cooperating with authorities was shot in a “professional hit” (The New York Times, 1977). In New Jersey, state authorities announced that a Genovese crime family associated with the Mafia infiltrated the broader healthcare industry (The New York Times, 1996).

Senator Moss, the author of the reports, and his staff, conducted 120 undercover operations at known Medicaid mills and found rampant criminal fraud (The New York Times, 1976). GAO found similar evidence of extensive patient abuse, criminal behavior, and fraudulent billing, and reported that federal action against Medicaid fraud and abuse had been minimal (GAO, 1975; GAO, 1976; GAO, 1977a; GAO, 1977b).

As a response, Congress amended the Social Security Act to allow states to obtain federal waivers to waive certain Medicaid requirements so that states could cover home or community-based services (HCBS) rather than requiring a senior to be placed in a nursing home (Omnibus Budget Reconciliation Act, 1981). Patients preferred to receive care at home, and Congress was concerned about explosive spending growth (Congressional Research Service, 2023). States were allowed to craft geographically targeted and population-specific packages, as long as they were cost-neutral, included patient protections, and were crafted with program integrity guardrails (Omnibus Budget Reconciliation Act, 1981). States were able to offer personal care attendants, adult day services, home modifications, and respite care to certain beneficiaries who would otherwise need nursing home-level care.

Unsurprisingly, personal care services suffered from the same criminal exploitation as home health. Fraud frequently took the form of organized criminal enterprise rather than isolated individual aides. In 1986, Professional Care Inc. was charged with $1.82 million in Medicaid reimbursement fraud, as the company allegedly had fabricated thousands of documents to mislead auditors about the use of unqualified aides (The New York Times, 1986). New York was spending $1.4 billion on personal care by 1990, so the HHS-OIG audited personal care services in Westchester County and found blatant fraudulent billing by personal care service agencies (HHS, 1994). Yet, in 1993, Congress formally added personal care services to the statutory list of Medicaid benefits, making physician authorization optional and allowing services to be provided outside the home (Omnibus Budget Reconciliation Act, 1993).

By the late 1990s, personal care services delivered through waivers had become a major component of Medicaid HCBS as states tried to shift long-term care away from institutions. However, it was an uphill battle to protect patients from criminal enterprise. Multiple federal reports warned of rampant criminal enterprise hurting patients and stealing taxpayer funds, including a stark report from the U.S. GAO on the proliferation of organized crime within the federal health programs, including the explosive growth of fraudulent personal care services (GAO, 1999; HHS, 2010; HHS, 2012a; HHS, 2016c; GAO, 2016). At the same time, lawmakers made significant reforms to the program focused on expanding access, with no parallel reforms on program integrity (Deficit Reduction Act of 2005, 2006; ACA, 2010). The first significant program integrity reform didn’t come until the 21st Century Cures Act, which required states to implement Electronic Visit Verification (EVV) (21st Century Cures Act, 2016). By Fiscal Year (FY) 2020, HCBS, including personal care services, had reached $116 billion in annual spending (KFF, 2022).

As part of the passage of the Working Families Tax Cut, policymakers instituted a broad suite of program integrity measures to combat the rampant fraud, like work requirements, more frequent eligibility redeterminations, and restrictions on provider taxes (One Big Beautiful Bill Act, 2025; America First Policy Institute[AFPI], 2025; Koch, 2026).The bill also included an expansion of HCBS to additional patients who were previously excluded (AFPI, 2025).

Modern Fraud Against American Patients & Taxpayers

Home health, hospice, and personal care services have all started as beneficial programs to support seniors in their home as they age. Over time, criminal enterprise has exploited these benefits, hurting American patients and stealing from the generosity of the American taxpayer. Policymakers should consider changes to these programs to protect beneficiaries and taxpayers alike.

Fraud within the Home Health Benefit

Medicare FFS home health spending reached $16.0 billion in 2024 for 2.7 million beneficiaries, with 12,234 Medicare-certified home health agencies participating in the program (MedPAC, 2026). MedPAC reported an average Medicare FFS payment of $6,031 per home health user, $2,057 per full 30-day period, and $245 per in-person visit in 2024 (MedPAC, 2026).

Under the current FFS home health benefit, beneficiaries are eligible for the benefit if they are 1) enrolled in Medicare Part A or B; 2) need skilled nursing care (on an intermittent basis), physical therapy, or speech-language pathology services, or continue to need occupational therapy; 3) are under a physician’s or allowed practitioner’s care; 4) receive services under a home health plan of care that a physician or allowed practitioner established and periodically reviews; 5) are confined to home (homebound); and 6) had a face-to-face encounter with a physician, nurse practitioner, clinical nurse specialist, physician assistant, or certified nurse-midwife that was related to the primary reason the patient requires home health services (HHS, 2026a).

Unlike Part A or Part B, the patient cannot sign up for home health. Access to the benefit is managed by a clinical referral and certification process. For example, a patient might be referred to a home health agency during a hospital discharge. Medicare requires a provider to order the home health care and certify that the beneficiary meets the coverage requirement. The physician or allowed practitioner assesses the patient and confirms that the patient is homebound (i.e., a leg wound preventing her use of a car). The patient is referred to various home health agencies and is able to choose between agencies willing and able to accept them. In 2024, 97% of FFS Medicare beneficiaries lived in a ZIP code served by two or more home health agencies, and 86% lived in a ZIP code served by five or more (MedPAC, 2026). The home health agency decides whether to accept the referral and assess the patient within 48 hours of referral or return home. The agency establishes a plan of care and orders the care to officially begin. Finally, the home health agency bills Medicare alone (the patient should have no cost-sharing) (HHS, 2026a).

Common Patterns of Fraud

Throughout this process, there are multiple opportunities for fraud. The first happens through patient recruitment. The HHS-OIG found that home health agencies violated the federal anti-kickback statute by compensating physicians, discharge planners, and other providers for referrals to their agency (HHS, 2016c). Some of these referrals may be legitimate, but HHS-OIG also found a pattern of practitioners falsely certifying patients as homebound or certifying them as eligible for medically unnecessary home health in order to get a kickback (HHS, 2016c; HHS, 2016a). Some home health agencies have gone so far as to pay recruiters to obtain Medicare numbers for billing purposes, without any certification at all (HHS, 2016a).

Once a real or fictitious patient is referred to a home health agency, the next well-documented pattern of fraud comes when the agency bills Medicare. The HHS-OIG’s nationwide analysis of home health fraud characteristics identified five claims patterns often seen in OIG-investigated fraud cases (HHS, 2016a):

1. No recent visit with the supervising physician;
2. No recent hospital or nursing home stay;
3. Primary diagnoses of diabetes or hypertension;
4. Beneficiaries receiving care from multiple home health agencies; and
5. Repeated readmissions shortly after home health discharge.

In one evaluation based on these criteria, the HHS-OIG found 562 home health agencies and 4,502 physicians that were statistical outliers on two or more fraud-associated characteristics in 2014 to 2015 claims data (HHS, 2016a). The OIG also found that Medicare reimbursed 562 outlier agencies $273 million for more than 100,000 episodes in 2015 (HHS, 2016a). They identified 27 geographic hotspots in 12 states, and those hotspots accounted for 35% of home health episodes and 37% of Medicare home health spending, equal to $6.9 billion in 2015 (HHS, 2016a). One unofficial analysis estimates roughly 194,000 beneficiaries are impacted, since criminals have to use real Medicare I.D.s to bill for care.

The crime is not simply defrauding the taxpayer. Criminals, like in the case of Ruby Scott, bribed a discharge nurse to obtain the confidential Medicare information of patients needing home health, and simply never provided care to the elderly patients (DOJ, 2026f). In another case, HealthNow Home Healthcare substituted nurse techs (and other nursing aides) for registered nurses when first meeting patients and designing care plans, going as far as telling their nurse techs to lie about being a registered nurse (DOJ, 2026g).

These patterns do not happen independently of one another, primarily because they share three structural weaknesses in the Medicare benefit design. First, provider enrollment is too easy, and provider revocation is too slow. For instance, a criminal can begin billing the Medicare program months before CMS can verify that their home health agency exists. Second, agency certification is documentation-based rather than physically verified. This means that a signed plan of care, submitted to CMS, will suffice, regardless of whether the doctor has ever seen the patient. Third, beneficiaries often do not know whether they have been enrolled, so detection depends entirely on audits rather than a senior raising a complaint. All five common patterns of fraud are consequences of these three weaknesses (DOJ, 2025d).

Organized Crime is Gaming Payment Rates

MedPAC found that Medicare home health payments far exceeded costs and that freestanding home health agencies had an aggregate Medicare FFS margin of 21.2% in 2024 (MedPAC, 2026). In addition, MedPAC reported that for-profit freestanding agencies had a 23.1% margin in 2024, compared with 12.2% for nonprofits (MedPAC, 2026). Even though enrollment in FFS is slowly dropping, MedPAC found that utilization rates have remained consistent—another fraud red flag (MedPAC, 2026).

CMS reported that the 2023 improper payment rate for home health claims was 7.7%, approximately $1.2 billion (HHS, 2025a).These improper payment estimates likely understate the full extent of criminal fraud, because CMS’s CERT program is not designed to detect sophisticated schemes such as identity theft, fabricated eligibility, or providers who repeatedly reappear under new ownership structures (HHS, 2024a).

Yet organized fraud, specifically in Los Angeles County, has also corrupted the claims data that CMS uses to set Medicare home health payment rates under the Patient-Driven Groupings Model (PDGM), implemented in 2020. PDGM replaced the former 60-day payment unit with a 30-day unit and bases payment on patient characteristics (clinical grouping, functional impairment, comorbidity adjustment, admission source, and timing) rather than therapy volume. Congress required the PDGM transition to be budget neutral, so CMS set the initial 2020 30-day payment amount so that aggregate Medicare expenditures would not increase solely because of the new payment model. CMS froze the PDGM budget-neutral payment baseline at approximately $16.6 billion for 2020 and uses that figure as the reference point for measuring changes in aggregate expenditures (HHS, 2019a).

CMS’s original assumptions concerned clinical-group coding, comorbidity coding, and agencies’ responses to the low-utilization payment adjustment (LUPA) threshold. Under PDGM, a 30-day period with visits below the applicable LUPA threshold is paid on a per-visit basis rather than the full 30-day rate, creating a financial incentive for agencies to manage visit volume (HHS, 2019a).

When fraudulent agencies in Los Angeles County expanded rapidly, they drove up claims and spending. When criminals submit high volumes of claims or change coding intensity, those claims may appear in CMS’s aggregate “actual behavior” data unless CMS identifies and excludes them. The fee schedule does not distinguish criminal billing from excess spending caused by lawful provider behavior. CMS interpreted this increase as legitimate provider behavior and used it to justify nationwide payment cuts (HHS, 2024c).

When legitimate agencies elsewhere closed, CMS treated those closures as a separate behavioral change and imposed further cuts. This is the mechanism by which criminal conduct can compound its harm: first, fraudulent claims increase program spending; then, if those claims are incorporated into aggregate payment-system calculations, the resulting reductions are spread across legitimate agencies nationwide (National Alliance for Care at Home, 2025).

Because the baseline itself is corrupted, CMS’s comparison of “assumed” versus “actual” behavior consistently finds an “overpayment,” which in turn justifies further reductions, creating a feedback loop that has accelerated the collapse of legitimate home health agencies nationwide. Between 2020 and 2025, Los Angeles County added more than 1,400 home health agencies, many operating with Medicare-only payer profiles, which is often a digital fingerprint of fraudulent operations. (U.S. House of Representatives, 2026). At the same time, more than 1,000 legitimate home health agencies closed across the rest of the country, leaving 2 million fewer beneficiaries without access to home health services (MedPAC, 2026; National Alliance for Care at Home, 2025).

Finding Fraudulent Providers: Beneficiary Turning

As discussed, CMS’s Medicare fraud analytics are generally provider- and billing-pattern-oriented. The detection focuses on billing outliers, cost anomalies, and ownership changes. The Fraud Prevention System assigns risk scores to individual providers based on their billing patterns. CMS and its Unified Program Integrity Contractors use billing spikes, peer comparisons, geographic analyses, and network mapping to identify any unusual activity (GAO, 2026). The most significant driver of home health and hospice fraud is “beneficiary-turning” schemes, which are coordinated operations that cycle the same Medicare beneficiaries through multiple agencies to repeatedly trigger new home health periods or hospice benefit initiations. These patterns are absorbed into payment analytics, making fraud-driven behavior appear national and legitimate, and fueling behavioral adjustments that do not reflect legitimate provider behavior. The HHS-OIG has found that fraud networks avoid these triggers by distributing claims across dozens of small agencies, thereby making them appear statistically normal. In the OIG’s nationwide analysis, 770 HHAs were statistical outliers for the share of beneficiaries receiving services from three or more HHAs, and six beneficiaries received services from at least 10 HHAs within two years (HHS, 2016a).

One of the most significant fraud patterns in the 2025–2026 enforcement record is the “closed-loop billing group” scheme documented in connection with Luxury Home Health (LHH). LHH billed 285 claims for 220 patients in March 2024, consistent with its high-volume billing pattern over the prior three years. Then, all 220 patients were discharged in a two-day window: March 12–13, 2024. No services were billed for seven months, from April–October 2024. Yet, billing resumed from November–December 2024. Obviously, legitimate home health operations do not follow this operational pattern. Of the 220 patients at LHH, 217 reappeared at other home health agencies almost immediately. For one partner agency (Nova Vita), 47 beneficiaries were admitted on the exact same day. The same beneficiary IDs moved repeatedly within the same home health agencies from 2019 through 2024, which was a key indicator that there might be a beneficiary trafficking operation (Luxury Home Health, 2026).

The data reveals a complex criminal enterprise, and many others follow the same components. First, the criminal enterprise has core high-volume agencies that are centered around PDGM billing. Second, they have home health agencies that absorb any excess beneficiary volume and can avoid fraud risks. Third, they have a top-level management structure that distributes beneficiaries, falsifies medical notes, and recycles beneficiary numbers when their other agencies are suspended or under scrutiny. This is often why provider-centric fraud detection methodology misses the most damaging schemes. Like in the case of LHH, none of their billing patterns were flagged because fraud was distributed across the entire network of home health agencies.

Fraud Hotspot: LA County

Vice President Vance and CMS Administrator Oz have repeatedly said Los Angeles is ground zero for hospice and home health fraud. MedPAC reported that Los Angeles County accounted for $1.4 billion in FFS home health expenditures in 2024, about 9% of national FFS home health spending, while representing only about 2% of the national FFS Medicare beneficiary population (MedPAC, 2026). MedPAC also reported that 16% of Los Angeles County FFS beneficiaries received home health services in 2024, more than twice the national average of 7.9% (MedPAC, 2026). A related letter from the leadership of the U.S. House of Representatives Committee on Energy & Commerce found that from 2019 through June 2023, the number of home health agencies in the United States fell from 8,838 to 8,280, while the number in Los Angeles County rose from 896 to 1,309 (U.S. House of Representatives, 2026). In addition, more than 1,400 new Los Angeles County home health agencies enrolled in Medicare over the prior five years, which represented more than 50% of California home health agencies and nearly 14% of all U.S. home health agencies (U.S. House of Representatives, 2026).

One documented case in LA County found that multiple agencies were tied to a single physician’s Medicare credentials. Dr. Gilbert Faustina billed nearly $600 million to Medicare between 2021 and 2024 (with nearly $210 million in 2024 alone and roughly 95 percent concentrated in Los Angeles County). In a short time, his associated patient count rose from about 9,700 to more than 29,500. Dr. Faustina stated he had never billed Medicare for these patients, received only a flat $3,000 monthly payment, and reviewed only a handful of charts. He did not know the providers using his number (La Jeunesse, 2026).

Another case in LA County is Fifth Avenue Home Health. Owners of Fifth Avenue Home Health were sentenced to prison after admitting they paid recruiters illegal kickbacks to bring Medicare beneficiaries to a clinic, then billed for home health services that were medically unnecessary or not provided. Recruiters drew patients in with offers of “free” power wheelchairs and diabetic shoes. In reality, Durable Medical Equipment (DME) carries a 20% coinsurance under Medicare Part B, so seniors had to pay for this equipment (unless the coinsurance was improperly waived, which is itself unlawful). Once enrolled, many seniors received little or no actual care while claims continued and they continued to pay (DOJ, 2019).

Rampant, criminal fraud hurts the historical mission of the benefit. After California imposed a hospice licensure moratorium, fraud activity shifted into home health. In 2025, 310 new home health agencies enrolled in Medicare in Los Angeles County. Patients and families encounter agencies listed at vacant or inappropriate addresses (strip malls, auto-parts stores, buildings with “for rent” signs) that have billed millions yet have no working phone, no staff, and no visible patients. When a patient later needs care, the association with a fraudulent agency can create administrative barriers, claim denials, or confusion that delays or blocks services (Gonzales, 2026). Vulnerable beneficiaries, like American seniors, are particularly exposed to these recruitment and billing tactics.

Not unlike the organized crime rings running “Medicaid mills,” criminal enterprise surrounding home health in LA County has been dominated by Armenian crime families (e.g., Mirzoyan-Terdjanian families, Artuni–Amiryan families, and others linked to Russian and Mexican Mafia syndicates) (DOJ, 2010; DOJ, 2025b)

Fraud within the Hospice Benefit

Medicare pays hospices largely through per diem rates for covered hospice care, and MedPAC reported an average Medicare hospice payment of about $191 per day in 2024 (MedPAC, 2026). MedPAC reported that Medicare hospice expenditures reached $28.3 billion in 2024, covering 1.82 million beneficiaries, 148.2 million hospice days, and 6,706 hospice providers (MedPAC, 2026).

To receive hospice, a patient must be entitled to Part A, be certified as terminally ill (meaning a medical prognosis of 6 months or less), and both the hospice medical director and the patient’s attending physician must certify the patient as terminally ill. The patient must voluntarily elect the hospice benefit, waiving Medicare payment for curative treatment of their terminal illness. The patient can revoke the election and return to curative treatment if needed. Coverage is provided in two initial 90-day periods, and an unlimited number of 60-day periods, assuming very few patients will need the second set of 60-day periods (time over six months). The hospice physician must recertify that the patient remains terminally ill, and at the start of each 60-day period, there must be a face-to-face encounter by a hospice physician or nurse practitioner (HHS, n.d.). The patient has no costs unless they’re paying for room & board, need long inpatient stays, or visit an Emergency Room. Patients can get routine home care, continuous home care, inpatient respite care, or general inpatient care. Hospice providers are paid a daily rate based on the level of care.

Common Patterns of Fraud

Throughout this process, there are multiple opportunities for fraud to occur. The most common and highest-dollar risk is when criminals enroll beneficiaries who are not terminally ill or bill for services that are not provided (DOJ, 2026b). For example, in April 2026, the Federal Bureau of Investigation (FBI) arrested a California couple for billing Medicare $5.2 million in hospice services for a patient population with a 97% five-year survival rate (DOJ, 2026b; Yamaguchi et al., 2026). MedPAC reported that among decedents, the average lifetime length of stay among hospice patients was 99.6 days in 2024, while the median was only 19 days. In other words, very long stays make up the majority of the spending—something not normal for patients in hospice (MedPAC, 2026).

Some patients are also enrolled in hospice without their knowledge or consent. Some will use recruiters and incentives to get people to sign hospice election statements, or others will go as far as stealing identities to bill Medicare (FBI, 2026; HHS, 2026h). For example, Traditions Health was exposed for paying kickbacks to physician medical directors who referred Medicare beneficiaries to its home health operations (DOJ, 2026b). Other criminal enterprise bills for services not provided, or refuses care to dying patients (DOJ, 2025e; HHS, 2018b). Lastly, criminal enterprise will use fraudulent billing until they are audited or capped by CMS, then closes, buys a new billing number, transfers patients, and resumes billing. There are many examples of this:

• The DOJ found that Topanga Hospice in Artesia, CA submitted more than $9.17 million in fraudulent Medicare claims and received more than $8.51 million, while 626 Hospice in Glendale, CA submitted more than $5.2 million in fraudulent claims and received more than $4.0 million (DOJ, 2026b). Both used extensive kickback schemes to recruit patients who were not terminally ill into signing an elective hospice benefit—meaning they were unable to use their Medicare benefit.

• The DOJ also found that One Up Hospice, Rosewood Hospice and Palliative Care, and Advance Hospice and Palliative Care in Glendale, CA submitted at least $4.8 million in claims and received at least $4.2 million, while Comfort Choice Hospice in Los Angeles, CA sought more than $3.8 million and received about $3.4 million (DOJ, 2026b). Elderly patients were recruited and tricked into getting hospice care, and denied care for legitimate, non-terminal conditions.

• Operation Skip Trace, conducted on April 8, 2026, by the DOJ with the assistance of California Department of Health Care Services and the California Franchise Tax Board, found 21 suspects in an alleged $267 million Medi-Cal hospice fraud scheme involving stolen identities, criminal Medi-Cal enrollment through Covered California, 14 hospice companies purchased by fake owners, and claims for hospice services that allegedly were never provided (California Department of Justice, 2026; DOJ, 2026b). California arrested five people and seized $757,000 in cash.
• One criminal was particularly prolific in perpetrating crimes against Medicare beneficiaries and the taxpayer. Dr. Rajiv Bhuva of Los Angeles, who appeared on Medicare hospice claims for nearly 2,800 patients across 126 California hospices in 2024. For comparison, the average California hospice physician appeared on claims for only 140 patients per year (Geller et al., 2026; U.S. House of Representatives Committee on Ways and Means, 2026). Since then, Bhuva has been barred from billing Medicare because of his criminal activity. Bhuva is significant not only because of the extent of his claims but also because he was a single physician serving as the medical director for 126 separate hospices. This is often referred to as a straw-medical-director scheme, where fraudulent hospices rent a real physician’s National Provider Identifier (NPI) to sign medical documents they would otherwise have no basis to support.

Hospice Fraud Leads to Beneficiary Harm

As historically designed, the hospice benefit is intended to let American seniors die, in their homes, with dignity and care. Instead, criminal fraud has led to widespread patient harm, denying seniors dignity in the end of their life.

At a U.S. House Committee on Ways and Means hearing on hospice fraud on April 21, 2026, Dr. Lynn Ianni testified that her Medicare number had been stolen and used to enroll her in hospice care. She discovered the identity theft when seeking treatment for a pickleball injury and was told that her Medicare benefits had been restricted because she was “already” in hospice (Geller, 2026; Ianni, 2026). A different Medicare patient who needed cataract surgery after a fall could not obtain it because records showed she elected into hospice. Sadly, she died two months later without the procedure (Ibarra, 2026). Another patient requiring a pacemaker battery replacement was blocked for four months until congressional intervention forced termination of the unauthorized election (Henry, 2026). Cancer patients have been denied chemotherapy, and individuals have lost access to dialysis or placement on transplant waiting lists (Kofman, 2022). At least one patient testified in a criminal case that Medicare refused coverage for a needed procedure solely because he had been listed as a hospice patient without his knowledge (HHS, 2026h). Patients were recruited with offers of free equipment or cash stipends ($300–$600 per month in some schemes) and later discovered they had forfeited curative coverage (DOJ, 2026c).

Unsurprisingly, in an industry rife with fraud, there is an increase in beneficiary harm. HHS uses reported hospice survey deficiencies as one measure of potential risk to beneficiaries (HHS, 2019a). The OIG found that from 2012 through 2016, more than 80% of surveyed hospices had at least one deficiency, and one-third of hospices providing care to Medicare beneficiaries had complaints filed against them (HHS, 2019a). The OIG also identified more than 300 hospices in 2016 as poor performers because they had at least one serious deficiency or one substantiated severe complaint, representing 18% of hospices surveyed nationwide that year. The most common deficiencies involved poor care planning, mismanagement of aide services, inadequate assessments, improper staff vetting, and inadequate quality control (HHS, 2019a). The report separately found that hospice beneficiaries can be harmed both by poor care and by abuse that hospices fail to address (HHS, 2019a). Beyond poor care, patients were hurt by insufficient reporting requirements, limited surveyor reporting requirements, barriers to complaints, inconsistent immediate-jeopardy citations, weak plans of correction, and the lack of intermediate remedies short of termination (HHS, 2019a).

The common thread is structural. Fraudulent enrollment converts a benefit designed for the dying into a barrier to needed care for the living. Policymakers should prioritize preventive enrollment integrity measures that make it harder for bad actors to obtain billing privileges, along with an expedited, low-burden process for beneficiaries to reverse unauthorized elections and restore full Medicare coverage. Intermediate civil monetary penalties, mandatory reporting of suspected harm regardless of perpetrator, and looking for outlier indicators (extreme live-discharge rates, physician concentration across dozens of agencies, rapid enrollment growth in high-risk markets) would further reduce the period during which beneficiaries remain exposed to both enrollment-driven access denials and substandard clinical care.

Fraud Hotspot: LA County

The California State Auditor’s March 2022 report concluded that weak oversight of hospice agencies created opportunities for large-scale fraud and abuse, particularly in Los Angeles County (California State Auditor, 2022). The report found that Los Angeles County had a 1,589% increase in hospice agencies between 2010 and 2021 and likely Medicare overbilling of $105 million in 2019, plus at least $3.1 million in likely Medi-Cal overbilling in FFS claims that the auditor said was likely understated. The California State Auditor reported that in 2021, Los Angeles County had an estimated 4.6 patients per hospice agency daily, compared with 56.3 daily patients per agency in the rest of California. The same audit found that a single Van Nuys commercial building housed 112 licensed hospice agencies and 49 home health agencies, and that 210 active hospice agencies were located within one mile of each other in Van Nuys.

The California State Auditor’s 2019 Medicare data showed a national hospice live-discharge rate of 11%, compared with 26% for Los Angeles County. Within LA County, the rates were extraordinarily high: 45% for North Hollywood, and 51% for Van Nuys. The audit also reported an average Medicare payment per hospice patient of $13,200 nationally, compared with $15,200 in Los Angeles County, $19,300 in North Hollywood, and $17,000 in Van Nuys. Los Angeles County had more than 31% of U.S. hospice agencies in 2022 but accounted for only 2.5% of the senior population in the United States (California State Auditor, 2022). Los Angeles County alone represented $3.5 billion in hospice fraud and 18% of all hospice billing in the United States (U.S. House of Representatives Committee on Oversight and Government Reform, 2026a).

Fraud within Long-Term Services & Supports

Fraud against seniors in Medicaid differs slightly from Medicare because Medicaid is a state-run program that relies on federal funding. Medicaid covered nearly one in five Medicare beneficiaries and paid for Medicare premiums and services not generally covered by Medicare, especially long-term care. In 2023, an estimated 5.1 million Medicaid long-term care users received home care, compared with 1.4 million who received institutional care. Meaning, roughly 78% of Medicaid long-term care users received services at home (Burns et al., 2026), making it rife for fraud in personal care services and other home-based services.

Seniors dually enrolled in Medicaid and Medicare can receive institutional care (primarily nursing facilities) and home- and community-based services (HCBS), including personal care services (PCS), home health aide services, adult day health, and various waiver supports. They are all authorized under different parts of a state’s Medicaid program: 1915(c) waivers, 1915(i) State Plan HCBS, Community First Choice (1915(k)), 1115 demonstrations, or managed LTSS (MLTSS) (MACPAC, 2022). In addition, eligibility requires both an eligible diagnosis or functional status and an eligible financial status—all of which differ from state to state (MACPAC, 2022; 42 C.F.R. § 441.715, 2026).

Common Patterns of Fraud

Similar to other home health and hospice care, LTSS generally requires a referral, an eligibility determination, a face-to-face assessment, and planning around the beginning of the service or treatment. There are many opportunities for fraud to occur, combining an especially vulnerable population with complexity in determining eligibility. Four structural features make them uniquely vulnerable. Low income makes kickback offers materially more effective. Medicaid pays for Medicare cost-sharing on the beneficiary’s behalf, so dual-eligibles rarely see the Medicare Summary Notice or Explanation of Benefits where a phantom claim would otherwise appear. And state Medicaid agencies and federal Medicare audit teams seldom share claims data in real time, meaning a fraudster billing for the same patient under both programs may not be caught until annual reconciliation.

The $548.8 billion in combined Medicare-Medicaid spending on dual-eligibles is therefore not only the largest single line item in U.S. senior health spending, but it is also the most exposed (MedPAC-MACPAC, 2025). Examples of fraud perpetrated in LTSS:

• Eligibility and enrollment. Fraudsters will often submit false or incomplete financial information (undisclosed assets, unreported transfers during the look-back, improper use of trusts, or misstated income) in order to increase the likelihood of a positive eligibility determination. They will also often collude with or put pressure on assessors to inflate a patient’s functional needs. Some fraudsters will enroll members of the family, receiving the payment but not delivering the benefit (DOJ, 2024a; HHS, 2018a).
• Service planning and authorization. Fraudsters will over-authorize hours or services beyond need and delivery, getting overpaid without delivering a benefit. They will also provide kickbacks or inducements for referrals into specific agencies or consumer-directed programs (DOJ, 2024b; HHS, 2012b).
• Service delivery and billing. This is the highest likelihood area of fraud. Criminals will bill for services not rendered (ghost visits, impossible hours, such as more than 24 hours in a day or concurrent services for multiple clients). They will also upcode the intensity or duration, submit claims while the attendant is incarcerated, working elsewhere, deceased, or out of the country. Many will falsify or manipulate EVV data, create blank or pre-signed timesheets, or collude with beneficiaries to split payments for non-provided care. In addition, the OIG found that many will use unqualified, unscreened, or otherwise excluded attendants (DOJ, 2026i; HHS, 2012a; HHS, 2024b; Nebraska Auditor, 2025).
• Ongoing management and recertification. Criminals take advantage of the weak oversight and recertification program and will knowingly collect payment for members no longer receiving care (HHS, 2015b; HHS, 2025c; New York State Office of the State Comptroller, 2024).

Medicaid Fraud Control Units (MFCUs) are often the agents responsible for addressing and controlling fraud. In FY25, they reported almost $2 billion in combined criminal and civil recoveries, including $1.3 billion in criminal recoveries and $706 million in civil recoveries (HHS, 2026b). MFCUs reported 1,185 convictions, 674 civil settlements and judgments, and 900 exclusions from federal health care programs in FY25. Unsurprisingly, HHS-OIG reported that personal care services attendants had the highest number of fraud convictions among provider types in FY25, which directly implicates home and community-based service oversight (HHS, 2026b).

Fraud Spotlight: Personal Care Services

Personal Care Services attendants are often the home aides who can help beneficiaries with bathing, dressing, meals, and mobility. Unfortunately, this is the single highest provider type for fraud convictions in FY25 (HHS, 2026b; DOJ, 2026d; HHS, 2012a; Texas OIG, 2026). The report found that common fraud patterns included attendants billing for hours not actually worked, supervisors falsifying timesheets, family-member attendants billing for care of relatives who do not need it or for hours when the relative was hospitalized, and kickback arrangements in which the recipient shares the PCS payment with the attendant. Because PCS is a benefit that operates almost entirely outside the institution, it is particularly challenging to provide oversight. Unlike a nursing home, there is no facility to inspect, no doctor to verify, and the “patient” is often the same person signing the timesheet. Policymakers should consider strengthening electronic visit verification, randomized in-home audits, and family-relationship disclosure requirements.

Fraud Spotlight: Skin Substitutes

Skin substitutes, also known as cellular and tissue-based products (CTPs) or wound grafts, are products applied to chronic wounds such as diabetic foot ulcers and venous leg ulcers. They are reimbursed under Medicare Part B and have become the fastest-growing item in Medicare fraud, defrauding the taxpayer, often reimbursed in conjunction with other home health services.

Medicare Part B spending on skin substitutes rose from $256 million in 2019 to more than $10 billion in 2024 (HHS, 2025c). The HHS-OIG found that costs for enrollees treated at home were four times higher than costs for those treated in office settings, and that utilization under Medicare Advantage (MA) was a small fraction of utilization under Original Medicare despite MA covering more than half of all enrollees (HHS, 2025b). Skin substitutes were historically reimbursed as biologics under Medicare Part B at the Average Sales Price (ASP). There are reports that manufacturers used this pathway fraudulently. First, they could bring products to market with inflated Wholesale Acquisition Cost (WAC) values and sell them to providers at deep discounts, keeping the delta. Second, manufacturers brought new products to market faster than ASP-based pricing could catch up, so they would continue to be paid at WAC-based reimbursement. The result was a perverse incentive for providers to switch to whichever product had the largest current spread (HHS, 2025b; HHS, 2025d).

In late 2025, two Arizona wound-graft company owners were sentenced to 15.5 and 14 years in federal prison, respectively, in what the DOJ called one of the largest medically unnecessary treatment schemes ever prosecuted (DOJ, 2025f). Over an 18-month period, the defendants submitted more than $1.2 billion in false claims to Medicare, TRICARE, and CHAMPVA; resolved $309 million in False Claims Act liability; forfeited cash, annuities, luxury vehicles, and precious metals totaling more than $1.2 billion (including nearly $100 million in cash); and paid hundreds of millions in kickbacks to themselves and tens of millions to sales representatives.

On April 28, 2026, federal agents seized more than $2 million from Expert Wound Care PC in Pasadena, California (DOJ, 2026e). The clinic collected $34 million in Medicare reimbursements on $46.6 million in submitted claims between September 2025 and March 2026. They averaged $299,639 per patient across just 78 beneficiaries. One beneficiary was billed $6.2 million, and Medicare paid more than $2 million for that single patient. Their billing grew by 600% in five months, from $4.975 million in July 2025 to roughly $33 million in December 2025. Police surveillance showed that the clinic was physically closed during periods when services were reported as being delivered.

Both cases had four defining features which align with the existing patterns of fraud in hospice and home health:

• Recruitment. Untrained sales reps recruited elderly Medicare beneficiaries, including hospice patients, and dictated which grafts were applied.
• Revenue-Directed Clinical Care. Nurse practitioners were instructed to suspend their independent medical judgment and apply whatever grafts the sales team ordered.
• Fraud and Abuse. Reports showed that large grafts were applied to small wounds, multiple grafts applied to single wounds, grafts applied to non-existent wounds, and grafts applied to terminally ill hospice patients (some of whom died the same day as application);
• Victim Double-Dipping. Hospice beneficiaries already exploited for hospice billing were billed again for skin substitutes.

ACL at HHS: Keeping Seniors Home and Fighting Fraud

The Administration for Community Living (ACL), housed within HHS, is the federal agency charged with maximizing the independence, well-being, and health of older adults, people with disabilities, and their families and caregivers. While CMS focuses on payment and clinical oversight of Medicare and Medicaid benefits, ACL operates the nation’s aging services network, including the Area Agencies on Aging, Aging and Disability Resource Centers, and Centers for Independent Living. In 2025 and 2026, ACL has been able to balance both anti-fraud initiatives with fulfilling the President’s promises on fraud.

The Health at Home Challenge

On April 23, 2026, ACL launched the Health at Home Challenge, a prize competition designed to improve health, independence, and affordability of care for dually eligible and near-dually eligible Medicare and Medicaid beneficiaries by scaling up certain community care networks. The challenge is structured around community care hubs (CCHs), which are entities that organize networks of community-based organizations (CBOs) to support whole-person health. The Health at Home Challenge is significant for two reasons. First, most critical health outcomes will occur outside of a doctor’s office or hospital but will instead occur in individuals' homes and communities. ACL is trying to scale up community care networks that deliver nutrition services, such as Meals on Wheels, evidence-based fall prevention programs, and care coordination. These directly address the non-clinical factors that determine whether a senior can remain at home. Second, the challenge prioritizes dually eligible beneficiaries, who are the same population that is the most exposed to home-based Medicare and Medicaid fraud. Priority areas for the challenge include California, Virginia, Maryland, Texas, Michigan, Ohio, Oregon, and Massachusetts, which overlap with the fraud hotspots identified by DOJ and CMS in the 2025–2026 home health and hospice enforcement actions.

Senior Medicare Patrol: Beneficiary-Level Fraud Surveillance

ACL maintains the Senior Medicare Patrol (SMP) program, a network of trained volunteers who educate Medicare and Medicaid beneficiaries, their families, and their caregivers about how to prevent, detect, and report health care fraud. It is the only federal program to empower Medicare beneficiaries to find out if criminals are using their benefits. Many of the most damaging fraud schemes discovered so far have involved beneficiaries who are enrolled in hospice care without their knowledge, who have their Medicare numbers stolen and used to generate phantom claims, or who are recruited by paid marketers to enroll in unneeded services. These fraud patterns are often invisible to CERT audits but can be found by Medicare beneficiaries. A patient who reviews their summary notice of charges and recognizes a fraudulent enrollment in a program can trigger an investigation that no audit algorithm would have initiated. The SMP provides a Medicare Tracker mobile application that allows beneficiaries to log their health care encounters and compare them against their Medicare claims, creating a personal audit trail. The SMP also coordinates with State Health Insurance Assistance Programs (SHIPs) to connect beneficiaries who have been fraudulently enrolled in hospice with counselors who can help them unenroll and restore access to the benefits they deserve.

Fighting Back: Trump Administration Efforts to Fight Fraud

All these programs share a common thread: policymakers have expanded these programs without sufficiently instituting program integrity measures. Home health, hospice, and LTSS have all grown, not just from utilization, but from criminal exploitation. The Trump administration has taken the first significant action in decades to crack down on fraud. The last significant action against fraud was the series of anti-fraud hearings led by Senator Moss in the 1970s. The whole-of-government approach is critical to hunt down and prosecute these criminals.

Cracking Down on Fraud: Vice President’s Task Force on Fraud

President Trump, when running for president, committed to crack down on fraud if elected (Roll Call, 2024). Just a month after he was elected, in February of 2025, the Department of Justice (DOJ) announced a major wave of fraud crackdowns. One California case exposed a $17 million scheme that was using ghost hospice companies and fraudulent home health certifications (DOJ, 2025a). Building on this, in June of 2025, the DOJ and the Department of Health and Human Services (HHS) announced the National Health Care Fraud Takedown, which resulted in criminal charges against 324 criminals who defrauded the American health care system. It was the largest health care fraud announcement to date: $14.6 billion dollars in transnational health care fraud against American patients, specifically older Americans (DOJ, 2025c).

In response to the immense theft of American seniors, President Trump signed Executive Order 14395 on March 16, 2026, to create the Task Force to Eliminate Fraud, chaired by the Vice President. It creates a government-wide strategy against fraud, waste, and abuse in federal benefit programs, including Medicare and Medicaid. The executive order gives agencies 30 days to identify the most fraud-susceptible benefit transactions, 60 days to coordinate minimum anti-fraud requirements, and 90 days to submit measurable implementation plans, with specific emphasis on eligibility verification, pre-payment controls, data sharing, provider revalidation, suspension, exclusion, debarment, and False Claims Act enforcement (Christenson, 2026; The White House, 2026a).

Later that month, on April 30, 2026, the DOJ’s newly created National Fraud Enforcement Division launched the West Coast Health Care Fraud Strike Force, operating permanent investigative teams in San Francisco, Las Vegas, and Phoenix. Modeled on the Florida Strike Force that has run since 2007, the West Coast force explicitly targets the hospice industry, wound care, telehealth, behavioral health, durable medical equipment, and sober homes.

On June 23, 2026, the Justice Department announced the 2026 National Health Care Fraud Takedown. It charged 455 defendants (including 90 licensed medical professionals) in schemes involving more than $6.5 billion in alleged false claims. CMS simultaneously suspended 1,079 providers and revoked billing privileges for 1,403 others. The cases spanned Medicare, Medicaid, hospice, wound care/skin substitutes, telehealth, and other high-risk areas, with significant activity in California and Arizona (DOJ, 2026g).

Then, on August 4, 2026, the DOJ’s National Fraud Enforcement Division announced charges against 19 defendants in Medicaid home health aide fraud schemes targeting Pennsylvania’s program. At the same time, it expanded the Northeast Health Care Fraud Strike Force to Philadelphia to increase permanent investigative capacity in that region (DOJ, 2026i).

In early August, Vice President Vance publicly updated the amount of fraud that the Task Force found:

• Approximately $230 billion in fraud identified.
• Approximately $56 billion in fraudulent payments stopped before they went out the door.
• More than $55 billion enforced through indictments, settlements, and civil penalties (The White House, 2026b).

On August 6, 2026, the White House launched fraud.gov (also called “The Fraud Ledger”), a public dashboard that tracks Task Force actions, agency-level recoveries, provider suspensions, indictments, and policy changes in real time (The White House, 2026c).

HHS Ramps Up Program Integrity Measures

Since the start of the second Trump administration, HHS has pursued an aggressive, data-driven shift from traditional “pay-and-chase” recovery to pre-payment detection, rapid suspensions, enrollment barriers, and state accountability measures.

Payment Suspensions and Pre-Payment Controls

CMS significantly expanded the use of payment suspensions based on advanced analytics and real-time monitoring. In 2025, CMS suspended approximately $5.7 billion in suspected fraudulent Medicare payments. This included more than $1.5–1.9 billion tied to durable medical equipment (DMEPOS), roughly $100–170 million for skin substitutes, over $100 million for laboratory billing, and smaller amounts for hospice and other high-risk areas (HHS, 2026e). As part of their fraud controls, CMS launched the Fraud Defense Operations Center (FDOC, also called the Medicare Fraud War Room) in March 2025. In its first year of full or near-full operation, it suspended payments to hundreds of providers totaling more than $1.8-2.1 billion (HHS, 2026g).

In 2026, large-scale targeted suspensions focused on hospice and home health, particularly in California. By May 2026, CMS had suspended payments to approximately 800 hospices and home health agencies in the Los Angeles area alone (responsible for about $1.4 billion in prior-year Medicare spending), with at least $70 million held in suspense accounts at that time. Additional suspensions continued in other high-risk states. During the June 2026 National Health Care Fraud Takedown, CMS suspended 1,079 providers. CMS also denied tens of thousands of claims through preliminary medical-necessity and coverage checks (HHS, 2026g).

Provider Revocations, Deactivations, and Exclusions

CMS and HHS-OIG sharply increased removals of providers from federal programs. In 2025, CMS revoked the Medicare billing privileges of 5,586 providers and suppliers due to inappropriate or fraudulent behavior. Many hospice revocations carried the maximum 10-year re-enrollment bar. CMS revoked the billing privileges of 1,413 just in the first quarter of the 2026, roughly a 40% increase over the same quarter the prior year (HHS, 2026e).

By early August 2026, CMS reported that 1,076 hospices in California had been removed from the Medicare program (an approximately 47% reduction from peak enrollment levels under the prior administration). Hundreds of additional hospice and home health providers were revoked or deactivated nationwide. HHS-OIG continued high volumes of exclusions (1,212 individuals/entities in one semi-annual reporting period; broader annual figures higher) and pursued civil monetary penalties. OIG also supported the June 2026 takedown with actions seeking more than $10 billion related to payments CMS had already suspended (DOJ, 2026g; HHS, 2026f).

Nationwide Enrollment Moratoria

CMS imposed three major temporary nationwide enrollment freezes to stop new bad actors from entering high-risk categories. On February 25, 2026, CMS announced a six-month nationwide moratorium on new Medicare enrollments (and certain majority-ownership changes) for specified DMEPOS medical supply company types. This built on the large volume of DME-related suspensions in 2025. Then, on May 13, 2026, CMS announced a six-month nationwide moratorium on new Medicare enrollments for home health agencies and hospices (including certain changes in majority ownership). Existing enrolled providers were not affected. CMS stated the freezes would allow intensified investigations, data analytics, and removals while preventing geographic shifting of fraudulent operations (HHS, 2026e; HHS, 2026j).

Medicaid-Specific Actions and State Accountability

CMS applied stronger financial leverage against states and launched dedicated Medicaid tools. Beginning in early 2026, CMS deferred large sums of federal Medicaid matching funds. Notable actions include approximately $259–350+ million deferred from Minnesota (starting February 2026, related to questionable claims and program-integrity concerns) and a record $1.3 billion deferred from California in May 2026. Additional deferrals and pressure continued into July 2026 (combined figures exceeding $1 billion for the two states in some announcements). CMS also sent program-integrity information requests to multiple states (HHS, 2026g; HHS, 2026h; HHS, 2026j; Mathers & Hinton, 2026).

In May 2026, HHS-OIG initiated reviews of every state’s MFCU ahead of annual recertification. At least one state (Hawaii) had recertification denied, discontinuing federal funding for that unit. HHS-OIG also denied New York’s 2026 MFCU recertification and suspended its federal grant, effective July 1, 2026 (HHS, 2026i; HHS, 2026j; Mathers & Hinton, 2026).

Enhanced Oversight Tools and Structural Changes

CMS expanded and layered enhanced enrollment screening, medical review, and site-verification tools to address fraud risks in Medicare home health and hospice. CMS’s Provisional Period of Enhanced Oversight (PPEO) subjects newly enrolling, reactivating, or changing-ownership hospices to heightened review; it initially applied to Arizona, California, Nevada, and Texas and was expanded to Georgia and Ohio effective December 30, 2025 (HHS, 2026d). CMS similarly expanded prepayment review of existing hospices to those six states. CMS has also conducted unannounced nationwide hospice site visits and has used enhanced enrollment screening for high-risk home health agencies, including site verification and fingerprint-based background checks (HHS, 2026g). Medicare enrollment rules separately authorize CMS to require providers and suppliers to disclose certain affiliations with entities associated with prior debts, payment suspensions, exclusions, enrollment denials, revocations, or terminations, and to deny or revoke enrollment when an affiliation presents an undue risk of fraud, waste, or abuse.

On February 25, 2026, CMS announced the Comprehensive Regulations to Uncover Suspicious Healthcare (CRUSH) initiative as a broader effort to strengthen program-integrity authorities across Medicare, Medicaid, CHIP, and the Health Insurance Marketplace (HHS, 2026e). CMS also intensified Affordable Care Act Exchange program-integrity enforcement. CMS reported that, over the preceding year, it ended premium subsidies for nearly 1.5 million people whom it identified as ineligible for financial assistance or enrolled without authorization on the federally facilitated Exchange. This included more than one million people affected by Medicaid/CHIP duplicate-enrollment or tax-credit reconciliation reviews and approximately 250,000 people whose unauthorized coverage was canceled. CMS estimated that these actions produced nearly $10 billion in annualized savings (HHS, 2026b).

Congressional Actions to Fight Fraud

The 119th Congress has been very active in combatting the waste, fraud, and abuse of the American health system by criminal enterprise. Most significant is the WFTC, which was passed on July 4, 2025. It provided a major structural Medicaid integrity overhaul, including community engagement and work requirements. It also included more frequent and stringent eligibility redeterminations, along with strict prohibitions on ineligible noncitizens getting healthcare paid by the American taxpayer (One Big Beautiful Bill, 2025).

The U.S. House of Representatives has passed eleven Committee on Oversight and Government Reform bills aimed at protecting taxpayer funds and combating rampant fraud and improper payments in federal programs, many of which address AFPI-supported recommendations and those cited in a recent GAO report (AFPI, 2026; Oversight and Government Reform, 2026b). The GAO estimates that between $233 billion and $521 billion is lost annually across all federal programs and operations due to fraud specifically. The report details fraud risks inherent in state-administered programs and provides Congress with insights to meaningfully address the problem. The package includes legislation that ensures that executive agencies have sufficient authority to stop or condition payments if there is an elevated risk of fraud (USHR, 2026h). In addition, the House has passed legislation that would establish a special office at the U.S. Department of the Treasury to investigate fraudulent claims and recovery, increased the tools and analytics available, creates data-sharing authority, and expands education and incentives for those who should be stopping fraud (USHR, 2026a; 2026b; 2026c; 2026d; 2026e; 2026f; 2026g; 2026i).

Another notable piece of legislation is H.R. 8883, the Protecting Seniors and Stopping Fraudsters Act. The legislation would require more frequent in-person surveys and inspections for newly enrolled hospices and home-health agencies or those with ownership changes. It would also require revalidation for high-risk providers. It would require enhanced enrollment screening for “extreme risk” providers (such as fingerprinting of administrators and medical directors). The bill would triple penalties if a provider failed to submit quality data. To address concerns about beneficiaries not knowing about their hospice notification, the bill requires the beneficiary to be notified when they are enrolled in hospice and are given clear disenrollment instructions. The bill would require stronger oversight and accountability for accrediting organizations and direct fraud efforts to focus on geographic hotspots, billing patterns, and discharge patterns rather than the rules currently in place (USHR, 2026j).

Policy Recommendations

As policymakers contemplate reforms to Medicare, Medicaid, and other senior care programs, they should consider strengthening anti-fraud tools in Medicare home health, restoring integrity to the home health payment system, and ensuring law enforcement has the resources needed to combat organized fraud over the long term.

• Realign the PDGM Baseline. The Patient-Driven Groupings Model's payment structure has created a perverse incentive that has attracted organized criminal enterprises into federal health programs. Congress should direct CMS to adjust the home health payment baseline methodology to exclude fraud-distorted claims data, and CMS should ensure that removing suspect claims from the baseline is not treated as further justification for rate reductions to legitimate, compliant providers.
• Increase Provider Screenings. CMS should strengthen beneficial ownership disclosure requirements, apply enhanced screening to high-risk provider categories, extend provisional oversight periods for newly enrolled agencies in fraud-prone areas, expand unannounced site visits, and implement beneficiary notification and confirmation systems to verify enrollment.
• Increase Front-End Identity Verification for Provider Enrollment. HHS should adopt identity- and data-verification tools comparable to those used in the private sector before enrolling providers, reducing reliance on self-reported, unverified applicant information by validating identity, ownership, and licensure through trusted third-party data sources.
• Strengthen Provider Revocation and Reenrollment Bars to Block Reentry Under New EINs. Bad actors whose Medicare enrollments have been revoked routinely reenter the program under new EINs or corporate shells, undermining existing reenrollment bars. Congress should codify mandatory cross-system matching of ownership and key personnel, automatic denial of applications linked to currently barred entities, longer or permanent bars for organized hospice and home-health fraud, and a real-time public registry that enrollment contractors must check
• County-Level Moratorium Authority. Policymakers should codify a mandatory moratorium trigger for any county where home health or hospice billing concentration exceeds three times the national per-beneficiary rate, with the moratorium lifting only after CMS completes site-visit verification of every enrolled provider in that county.
• Target Hospice Terminal Illness Certification Fraud with Independent Review and Accountability Measures. False certifications of terminal illness remain a central driver of hospice fraud, enabling enrollment of non-terminal patients and high live-discharge rates. Policymakers could require independent (non-affiliated) physicians to perform initial certifications, mandate medical-review triggers for outlier discharge and length-of-stay patterns, authorize penalties for physicians with repeated ineligible certifications, and direct CMS to publish physician-level outlier data.
• Expand Independent, Third-Party Fraud Audits. Current oversight, including existing Recovery Audit Contractors (RAC) and Unified Program Integrity Contractors (UPIC) audits, often focus on financial and billing compliance rather than detecting sophisticated fraud schemes and organized criminal networks. HHS should expand the use of specialized third-party auditors and data analytics vendors trained to identify organized fraud patterns, not just billing errors. Policymakers could consider authorizing new contractor authority, expanding the scope for existing contractors, or both.
• Provide Dedicated, Expanded Resourcing for UPICs. UPICs serve as the primary front-line investigators of organized Medicare fraud, conducting data analytics, site visits, and referrals across home health and hospice claims, yet experts have been concerned with funding levels for the scale of schemes in high-risk areas. Congress should consider authorizing a funding increase for UPIC task orders focused on these hotspots, expand capacity for network-level detection, require stronger coordination with state MFCUs and HHS-OIG, and tie performance metrics to disruption of multi-entity fraud rings.
• Real Time Data Sharing. Policymakers should mandate real-time or near-real-time data sharing between state MFCUs and CMS's Medicare audit teams. Current data lag and format mismatches between MFCUs and CMS are frequently cited as a major bottleneck to timely enforcement action.
• Create a Victim Unenrollment Mechanism. CMS should establish an expedited unenrollment process for beneficiaries fraudulently enrolled in hospice, without requiring clinical certification when fraud is alleged. To prevent misuse as a care-disruption vector, this should function as a fraud-alert flag with a fast-track re-enrollment path into legitimate hospice care, rather than a blanket disenrollment.
• Integrate Senior Medicare Patrol Outreach into CMS’s Enhanced Oversight Program. In counties subject to provisional enhanced oversight, ACL should deploy targeted SMP campaigns in the highest-density hospice and home health ZIP codes, and CMS should promote the SMP Medicare Tracker app to beneficiaries in those areas as a personal tool to flag phantom claims and unauthorized enrollment.
• Use the Health at Home Challenge to Build Fraud-Deterrent Community Infrastructure in Enforcement Hotspot States. Challenge submissions from those states should be evaluated in part on their capacity to connect dually eligible beneficiaries to trusted community navigation services that reduce isolation and susceptibility to fraudulent recruitment.

Conclusion

Fraud targeting American seniors is a profound breach of trust that exploits the vulnerability of older Americans, erodes their independence, and undermines the American healthcare system. As the aging population grows and fraud schemes become increasingly sophisticated, it has become more urgent that the American government respond to and prosecute these criminal enterprises. Policymakers need to consider extending beyond enforcement to include proactive education, stronger consumer protections, improved data-sharing across agencies, and targeted policy reforms to address systemic gaps. Protecting seniors as a critical part of our American society requires a whole-of-society approach that empowers individuals, equips caregivers, and holds perpetrators accountable.

[1] Improper payments are not fraud-rate estimates and often reflect missing documentation rather than criminal intent. However, improper payments are increasingly indicative of criminal behavior.

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