Private Duty Fraud Enforcement

Admin

by Elizabeth E. Hogue, Esq. | Sep 4, 2026 | Admin, Clinical, Home Care, Medicaid, Waste Fraud and Abuse

by Elizabeth E. Hogue, Esq.

The Future of Private Duty/Home Care

It Begins with Fraud Enforcement

Use of private duty/home care services continues to increase. It has become increasingly clear, however, that companies will not be permitted to care for patients who need these services without considerable additional oversight.

The proverbial “bottom line” is that private duty/home care companies will be under greater scrutiny and regulation. The instances of gross mistreatment of patients, some of which we have described in previous articles, are too shocking and lurid. And caregivers about whom lip service is given about their need for support have been mistreated by private duty companies.

And Then There's This:

The feds are convinced that there is rampant fraud in state Medicaid Programs to the tune of millions, if not billions, of dollars that has not been addressed. The number of fraud strike forces, task forces, etc. targeting companies that provide services to Medicaid recipients are now too numerous to count.

Fraud enforcement is definitely “in fashion” and enforcers are eager to put private duty/home care companies in the color orange! If this a fashion statement you want to make?

To Illustrate:

The National Fraud Enforcement Division of the U.S. Department of Justice (DOJ) recently announced that it has prosecuted 6200 defendants who collectively billed federal health care programs, including Medicaid, TriCare, the VA and others, $45 billion.

In a press release issued on August 4, 2026, the Division stated:

“Home care fraud is everywhere, and the victim is all of us taxpayers. Medicaid claims date and the experience of veteran prosecutors all point to the systematic exploitation of reimbursable home care programs….Today. we sound the alarm on the scale of this fraud by announcing some truly egregious cases, in which numerous people are charged with filing fraudulent claims for caregivers who were not actually providing home care services, but in fact were dead, in prison, or trafficking drugs. This racket ends today.”

And There's More!

“Let today’s announcement be a warning to those engaging in similar activity: if you seek to exploit our health care systems for personal profit, you should expect the FBI and our partners to uncover your scheme and bring it to an end. Every dollar stolen through fraud is a dollar diverted from patient care, and the FBI will continue its work to safeguard the public’s trust and hold accountable those who abuse these vital programs.”

Finally the press release promises that enforcers “…will pursue anybody who seeks to profit at the expenses of American taxpayers, regardless of whether the wrong doing is in the boardroom or in the sickroom.”

In other words, it’s not just the perpetrators who will be punished. The companies, owners and managers will also face punishment.

So, what are some of the offenses pursued so far?

One of the defendants was captured on tape:

”This home health care is the best kept secret…I made a buck plus (each of) the last five years. That’s a half million dollars… ain’t checking on nobody.”

It may be tempting for owners and managers to say: “That’s on them.” Not so! Companies and management will be held accountable for the actions of their employers and contractors.

Private duty/home care companies will see a tsunami of regulation. Use of fraud and abuse prohibitions is just the beginning.

# # #

Elizabeth E. Hogue, Esq The Rowan Report

Elizabeth Hogue is an attorney in private practice with extensive experience in health care. She represents clients across the U.S., including professional associations, managed care providers, hospitals, long-term care facilities, home health agencies, durable medical equipment companies, and hospices.

©2026 Elizabeth E. Hogue, Esq. All rights reserved.
No portion of this material may be reproduced in any form without the advance written permission of the author.

Update: CMS Response to Arizona Hospice

Admin

by Tim Rowan | Aug 7, 2026 | Admin, Advocacy, CMS, Hospice, Waste Fraud and Abuse

by Tim Rowan, Editor Emeritus

Update: CMS Sides with NGS in Arizona Hospice Case

Letter Says "Typos Count"

We are sad to have to report that CMS has rejected the evidence that a hospice’s report of change of ownership was due to a typo. The consultant retained to help with their appeal received this letter.

The CMS Letter

Thank you for your email. Based on our review, we do not see any issues with the revocation decision. The provider did file a reconsideration, and on May 6, 2026, we issued a decision upholding the 42 C.F.R. § 424.535(a)(8)(ii) revocation. Their main argument is that there was no change in ownership and, as a result, they should not have been subject to PPEO. However, the applications submitted by the provider clearly reflected 100% changes in ownership. In addition, the provider had an 80% PPEO claim denial rate, and none of these denials were overturned on claim appeal. Please note that the provider filed an appeal with the ALJ on June 18th. Given that the case is pending, we should not take any other action until the appeal has concluded.

Best Regards,

Anaga Nmagu, JD.
Director, Division of Provider Enrollment Appeals
Provider Enrollment & Oversight Group
Center for Program Integrity
Centers for Medicare & Medicaid Services
Office: (410) 786-4690
Email: anaga.nmagu1@cms.hhs.gov

Home Health and Hospice Respond

The more stories we can collect about CMS contractors overstepping their authority, improperly denying claims, up to and including putting honest providers out of business, the more convincing we will be when we confront the perpetrators. We urge you to tell us your stories. We will never publish your name.

If you, a client, or someone you know has stories about CMS contractors, please reach out to editor@therowanreport.com or tim@rowanresources.com.

# # #

Tim Rowan is a 33-year home care technology consultant who co-founded and served as Editor and principal writer of this publication for 25 years. He continues to occasionally contribute news and analysis articles under The Rowan Report’s new ownership. He also continues to work part-time as a Home Care recruiting and retention consultant. More information: RowanResources.com
Tim@RowanResources.com

©2026 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

Formal NGS Complaint Submitted to OIG

CMS

by Tim Rowan | Jul 31, 2026 | CMS, Hospice, Medicare, Waste Fraud and Abuse

by Tim Rowan, Editor Emeritus

Formal NGS Complaint Submitted to OIG

Hospice Wrongly Subjected to PPEO Fights Back

Two weeks ago, we reported on an Arizona hospice that found itself in the middle of a revalidation survey when its Medicare Administration Contractor incorrectly classified it as a new provider. NGS placed the hospice under Provisional Period of Enhanced Oversight (PPEO) and promptly terminated its owners following a separate, 10-claim audit. (See “NGS Shutters Valid Hospice” – July 17)

According to this hospice’s PECOS file, no change of ownership — or any other triggering event that would justify reclassification — ever occurred. The error led to a clinical review of a handful of claims, a determination of fraudulent billing, and a 10-year ban against the owners.

On Monday, July 27, the hospice submitted a formal complaint to the Office of the Inspector General at HHS regarding NGS practices. According to the Medicare consultant retained by the hospice, the formal referral became necessary after a letter to CMS Administrator Dr. Mehmet Oz, describing multiple missteps by NGS, went unanswered. A subsequent video meeting with low-level CMS staff resulted only in a defense of the contractor.

Executive Summary

The hospice allowed us to publish a general summary of the complaint, provided we do not share its name at this stage. The OIG referral documents specific instances that the complainant asserts are representative of a “systemic pattern of misconduct by Medicare contractors.”

The complaint says that such misconduct “enriches contractors at the expense of providers and the Medicare Trust Fund.” It further notes that offending contractors continue to operate with CMS trust while the Center’s leadership remains focused only on a limited number of fraudulent providers.

Demand for Restitution and Reform

Dr. Mehmet Oz shifted uncomfortably in his chair, a look that signaled something between frustration and distress clouding his famous face. The new CMS Administrator removed his reading glasses, laid the Medicare consultant’s letter on his desk, thanked his aide for handing it to him, and asked her to close the door behind her as she left. Who he may have called next is anyone’s guess, but he did have a staffer tell the letter-writer, “We called the MAC; they said they didn’t do it.”

The complaint calls for meaningful reform that restores fairness to providers whose practices have been terminated. It demands restitution for owners who have been placed on the Preclusion List for ten years, often based on improper classifications.

The OIG referral specifically requests that:

CMS take immediate investigative action
All affected providers receive restitution with interest, and
CMS subject the entire contractor model to a thorough audit, similar in rigor to prior OIG reviews that uncovered widespread errors in contractor processes, some going back decades.

The complaint emphasizes that, while effective detection and elimination of actual fraud is essential, it must not come at the expense of compliant providers.

Strength in Numbers: Protect Your Agency

As we did in our first report of this series, we are opening our doors, well, our contact information anyway, to all Home Health and Hospice providers in the Medicare program. CMS may be able to ignore evidence from one or two providers, but a larger volume of consistent reports is harder to ignore. Write to us at editor@therowanreport.com, or Tim@RowanResources.com. If putting your story in writing makes you nervous, call me at 719-499-8902. You have seen how I protect the identity of the two providers outlined in this story. I will do the same for you.

We also have ways to help you find assistance to write your own OIG complaint. Once we get 100 or more complaints submitted, we will have status to demand Congressional hearings. You can be part of the solution.

# # #

Tim Rowan is a 33-year home care technology consultant who co-founded and served as Editor and principal writer of this publication for 25 years. He continues to occasionally contribute news and analysis articles under The Rowan Report’s new ownership. He also continues to work part-time as a Home Care recruiting and retention consultant. More information: RowanResources.com
Tim@RowanResources.com

©2026 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

Justice Department’s Next Target

Medicaid

by Kristin Rowan | Jun 19, 2026 | Medicaid, Waste Fraud and Abuse

By Kristin Rowan, Editor

Justice Department's Next Target

New York Sued for Fraud

The past several months, Vice President JD Vance, Dr. Oz, and the anti-fraud task force have investigated home health and hospice agencies suspected of fraud. Much of the focus has been in Minnesota, Georgia, and California. Now, New York joins the list of targeted states, as the Justice Department suis the New York State Department of Health, the state’s Medicaid director, Public Partnerhsips, LLC (PPL), the company operating the $10 billion Consumer Directed Personal Assistance Program (CDPAP) for the state.

CDPAP Management

Prior to the fall of 2024, CDPAP was managed by hundreds of individual agencies. The state opted to consolidate management into one firm and selected PPL. At the time, CDPAP was one of the largest public health benefits programs in the state with more than 250,000 patients.

Justice Department Allegations

Skimming

In the lawsuit, the Justice Department alleges unauthorized profits going to PPL. These profits allegedly come from PPL skimming a percentage of each hour of care billed to Medicaid. The skimmed percentage, according to the suit, amounts to millions of dollars.

Favored Vendor

The Justice Department further alleges PPL was untruthful in its bid regarding its staffing plan, its financial readiness to handle the contract, and the quality of its software, among other aspects of the plan.

The Department of Justice is blaming New York Governor Kathy Hochul and her administration for allowing the fraud. The DOJ alleges PPL was “preselected” as the winner of the contract in a fixed bid process.

Misrepresentation

The lawsuit further alleges that PPL won the contract after a “sham bid” process. The Justice Department claims PPL intended to stray from the representations made in their bid, that the New York Department of Health learned of the deceit, and failed to hold PPL accountable.

JD Vance Speaks

At a recent campaign event, Vice President JD Vance spoke about the lawsuit.

“You do not want your government facilitating fraud; you want your government fighting against fraud. You know what these fraudsters are doing? They’re taking advantage of American generosity to enrich themselves.”

JD Vance

Vice President of the United States

Response

New York State Department of Health spokesperson Cadence Acquaviva called the lawsuit a “baseless complaint” and an attempt by Republicans to “score political points at the expense of vulnerable New Yorkers.” Acquaviva called the lawsuit “inexcusable and completely lacking in merit.”

The Rowan Report reached out to PPL for comment, but did not hear back as of the publication of this article. We will provide updated information as it becomes available.

# # #

Kristin Rowan is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news. She is also a sought-after speaker on Artificial Intelligence, Technology Adoption and Lone Worker Safety. She is available to speak at state and national conferences as well as software user-group meetings.

Kristin also runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. She works with care at home software providers to create dynamic content that increases conversions for direct e-mail, social media, and websites. Connect with Kristin directly at kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2026 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

Fraud in Hospice

Hospice

by Elizabeth E. Hogue, Esq. | May 29, 2026 | Hospice, Waste Fraud and Abuse

By Elizabeth E. Hogue, Esq.

Fraud in Hospice Today

Between a Rock and a Hard Place

The crackdown on fraud in the hospice industry has begun and will undoubtedly continue for some time. Many believe that this crackdown is way overdue. Efforts to eliminate fraud are likely to negatively impact the hospice industry; causing significant damage or even destruction of its credibility. The result may be that patients are no longer willing to receive hospice care. These negative effects could spill over to other types of services provided in patients’ homes, such as home health services.

Examples of Fraud in Hospice

Placed in Hospice Care Without Knowledge

A former Louisiana resident was sentenced to 6 years in prison for conspiracy to commit health care fraud and 3 counts of health care fraud. Evidence presented at trial demonstrated that 24 patients were admitted to the hospice who had not been diagnosed with a terminal condition. Many of the patients and their families never knew they had been placed in hospice care. A patient testified at trial that Medicare refused to cover a procedure he needed because, without his knowledge, he was a patient of a hospice.

Fake Charts

A defendant in California told prospective patients that they did not have to be dying to receive hospice services. After collecting identifying information from prospective patients who were not terminally ill, the hospice billed the Medicare Program for services provided to the patients. When the Medicare Program requested additional information to support claims submitted, the owners directed employees to create fake patient charts that were submitted to Medicare.

Make the Patient go "Bye-Bye"

A Texas hospice owner sent employees a text that said, “You need to make this patient go bye-bye.” Giving the owner every benefit of the doubt and allowing for misunderstandings that may arise from text messages, it seems impossible to justify this communication.

Another owner of a hospice in Texas sent a text message to a hospice nurse telling her to take over for nurses who weren’t doing their jobs. The owner went on to say: “I told this chick that if she would just give her 1 ml of Ativan and turn her she would die,” and “[expletive] woman is still alive…I need boots on the ground.” After the nurse took over the care of the patient, as instructed, the owner then texted “nice work.”

Hospice Without a Terminal Illness

A physician was the medical director of several hospice companies. He fraudulently certified that patients of these hospices had terminal illnesses when they did not. In 2015, the physician was listed as the attending physician for more hospice claims paid by the Medicare Program than any other doctor in the country.

Kickbacks

The medical director of another hospice with dozens of locations certified unqualified patients for hospice care. In addition to payment for his services as medical director, he received other perks, including luxury trips and bottle service at exclusive nightclubs.

Final Thoughts

The need for enforcement action is clear, but what effect will these efforts have on the general public and the public’s willingness to use hospice and other services? The backlash from learning that providers who are supposed to care for patients and their families in their dying moments actually engaged in fraudulent conduct may be horrendous – even catastrophic – in terms of utilization of hospice services. Even compliant hospices and other types of providers may feel severe adverse effects. So sad for everyone.

# # #

Elizabeth Hogue is an attorney in private practice with extensive experience in health care. She represents clients across the U.S., including professional associations, managed care providers, hospitals, long-term care facilities, home health agencies, durable medical equipment companies, and hospices.

©2026 Elizabeth E. Hogue, Esq. All rights reserved.
No portion of this material may be reproduced in any form without the advance written permission of the author.

Alliance Responds to CMS

Advocacy

by Rowan Report | May 14, 2026 | Advocacy, CMS, Medicare, Regulatory, Waste Fraud and Abuse

FOR IMMEDIATE RELEASE

Contact: Hannah Kristan
communications@allianceforcareathome.org
202-355-1647

The Alliance Responds to CMS’s Announcement of Nationwide Enrollment Moratoria on Hospice and Home Health Providers

Washington, D.C, May 13, 2026. On May 13, the Centers for Medicare & Medicaid Services (CMS) announced a six-month national moratorium on hospice and home health enrollment in response to program integrity concerns within the Medicare programs. While the National Alliance for Care at Home (the Alliance) strongly supports efforts to root out bad actors who exploit these essential programs, undermine confidence in care at home, and threaten the patients and families who depend on it, the Alliance has long advocated for targeted strategies that distinguish between high-fraud markets and communities where fraud is not an identified problem and patients already face shortages of providers.

Concerns

The Alliance welcomes the Administration’s focus on combatting fraud, waste, and abuse and appreciates that CMS has indicated providers will still be able to conduct face-to-face recertification visits via telehealth during the enrollment moratorium, which will help avoid unnecessary care disruptions for patients and families. However, an enrollment moratorium does not distinguish between bad actors and compliant providers and will ultimately reduce competition and slow innovation. More importantly, an enrollment moratorium raises serious access-to-care concerns in areas where patient demand is growing or existing capacity is already strained, leading to longer wait times, reduced service availability, and fewer choices for patients – particularly in rural or underserved communities.

Less Severe Recommendations

Public reports show that fraud is concentrated in specific geographies and among specific actors, signaling that targeted reforms and oversight strategies are needed to identify and remove fraudulent entities from the Medicare program. The Alliance and other national organizations have repeatedly provided CMS with recommendations that focus on preventing bad actors from entering the Medicare and Medicaid programs and better leveraging existing tools to fight fraud without creating unnecessary burden for good-faith providers who are already meeting program requirements.

From the Alliance CEO

“The majority of home health and hospice providers deliver compliant, patient-centered, and clinically appropriate care to individuals with complex needs, often in their most vulnerable moments. CMS must use data-driven, risk-based program integrity measures and focus resources on boots-on-the-ground surveys and enforcement of existing oversight mechanisms that root out the blatantly bad actors without potentially limiting patient access to care or punishing high quality providers operating in good faith.”

Jennifer Sheets

CEO, National Alliance for Care at Home

Final Thoughts

This moratorium, effective May 13, applies only to new providers and certain changes of ownership, and may be extended if CMS deems it necessary.

The Alliance has been and will remain a proactive, constructive partner to Congress and federal regulators on program integrity efforts. The Alliance will continue to engage with the Administration on a path forward that holds bad actors accountable while protecting patient access to the safe, high-quality care at home they need and deserve.

# # #

About the National Alliance for Care at Home

The National Alliance for Care at Home (the Alliance) is the leading authority in transforming care in the home. As an inclusive thought leader, advocate, educator, and convener, we serve as the unifying voice for providers and recipients of home care, home health, hospice, palliative care, and Medicaid home and community-based services throughout all stages of life. Learn more at www.AllianceForCareAtHome.org. 

Medicare Moratoria

Breaking News

by Kristin Rowan | May 14, 2026 | Breaking News, Medicare, Regulatory, Waste Fraud and Abuse

by Kristin Rowan, Editor

Medicare Moratoria

CMS Halts All New Home Health & Hospice Agencies

As part of it’s ongoing efforts to curb Medicare waste, fraud, and abuse, the Centers for Medicare and Medicaid Services (CMS) is taking a bold step. On Wednesday, May 13, 2026, CMS announced a 6-month moratoria on home health and hospice agency enrollment. Aimed at protecting Medicare beneficiaries and taxpayer dollars, the moratoria will temporarily stop new enrollment of providers in home health and hospice, which CMS calls “high-risk” categories and key sources of fraudulent activity. CMS states this effort builds on additional fraud prevention initiatives, including enhanced screening, site visits, and expanded oversight activities across the hospice and home health sectors

More Investigations

Together with Vice President JD Vance’s Anti-Fraud Task Force, CMS will increase its targeted investigations of hospice and home health agencies that are suspected of fraud. CMS promises to use advanced data analytics and to accelerate the removal of fraudulent hospice and home health agencies.

Skirting Authority

CMS investigations revealed that some agencies intent on committing fraud are closing their businesses and reopening under different names in different states to perpetrate additional fraud. The moratoria will prevent these agencies from skirting authority in this manner. Additionally, the moratoria applies to some changes in ownership, which is a common technique used to hide these “bad actors.”

What it Means for You

The moratoria do not apply to existing providers with current enrollments. You can continue to deliver services to Medicare beneficiaries as long as your enrollment is current and in good standing.

Statement from CMS

“We’ve seen systemic and deeply troubling fraud in the hospice and home health space, with bad actors exploiting some of our most vulnerable Medicare patients and stealing money from the American taxpayer. Today we’re shutting the door on fraud—preventing new bad actors from entering Medicare while we aggressively identify, investigate, and remove those already exploiting them. This is about protecting patients, restoring integrity, and safeguarding taxpayer dollars.”

Dr. Mehmet Oz

Administrator, Centers for Medicare and Medicaid Services

More Information

The administration’s anti- fraud, waste, and abuse efforts are ongoing.

Read the CMS Press Release

Full text of the Home Health Moratorium

Full text of the Hospice Moratorium

# # #

Kristin Rowan is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news. She is also a sought-after speaker on Artificial Intelligence, Technology Adoption and Lone Worker Safety. She is available to speak at state and national conferences as well as software user-group meetings.

Kristin also runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. She works with care at home software providers to create dynamic content that increases conversions for direct e-mail, social media, and websites. Connect with Kristin directly at kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2026 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

Private Payors Against Fraud

Admin

by Elizabeth E. Hogue, Esq. | Apr 17, 2026 | Admin, CMS, Home Health, Hospice, Medicaid, Medicare, Regulatory, Waste Fraud and Abuse

by Elizabeth E. Hogue, Esq.

Private Payors Against Fraud

Join Enforcement Efforts

There seems to be a persistent myth among providers of private duty/homecare services that the federal anti-kickback statute applies to Medicare-certified providers only. On the contrary, the anti-kickback statute applies to providers who receive funds from any state or federal healthcare program; including the Medicaid Program, VA, TRICARE, etc. Private duty providers: This means many of you! Lately it has become clear that private payors have joined fraud enforcement efforts.

Guilty

In a recent case, a provider in Detroit pled guilty to conspiring to commit health care fraud. The conspiracy resulted in losses totaling $1.9 million to Medicare, Medicaid, and Blue Cross Blue Shield of Michigan. The investigation was conducted by the FBI and the Office of Inspector General of the U.S. Department of Health and Human Services, the primary enforcer of fraud and abuse prohibitions.

Ghost Services

At the plea hearing, the provider admitted to creating and operating a scheme to submit false and fraudulent claims that were medically unnecessary or not actually provided. In some instances, services billed were not ordered by physicians. The scheme continued for over five years. The provider used the proceeds of fraud for his personal use and to benefit others.

Consequences

After a presentence report is prepared, the provider faces a possible maximum sentence of ten years in prison, a fine of up to $250,000 and up to three years of supervised release following any term of imprisonment.

Federal and Private Prosecution

It is important to note that the provider was criminally prosecuted not only for fraud with regard to claims submitted to Medicare and Medicaid Programs, but also fraud committed against a private payor, Blue Cross Blue Shield.

Your Payor Could Report You

It now appears that providers who receive payments from third party payors must be concerned about fraud enforcement. Consequently, providers of private duty/home care services must develop, implement, and update Compliance Programs.

Compliance Programs

Compliance Programs are specific types of documents that routinely address issues that providers do not usually cover in internal policies and procedures. In addition, providers may not gain benefits related to fraud enforcement if there is no formal document called a Compliance Program.

More than Accreditation

Some providers think that accreditation means they are in compliance. On the contrary, providers may be accredited but fail to meet applicable compliance standards for fraud and abuse. Compliance Programs appropriately address potential fraud and abuse issues. They also include mechanisms for helping to ensure compliance, such as processes for identification and correction of potential problems that are not addressed during the certification process.

It Could Save You

Providers also need to know that developing, implementing, and updating Compliance Programs may make a considerable difference during fraud enforcement actions. If providers have Compliance Programs in place that are current and fully implemented, enforcers may be less aggressive in pursuing potential violations.

Corporate Integrity Agreement

When enforcers discover problems with fraud and abuse in organizations, providers are usually asked to develop and implement a Corporate Integrity Agreement (CIA). This type of agreement is likely to include processes for stringent monitoring on a continuous basis. These monitoring activities can be extremely burdensome to providers in terms of both time and money. Providers with valid Compliance Programs are not necessarily asked to develop and implement CIA’s.

Final Thoughts

Now is the time for all providers, including private duty/home care companies, to recognize and act upon the need to establish and maintain Compliance Programs. “Working on it” is no longer good enough.

# # #

Elizabeth Hogue is an attorney in private practice with extensive experience in health care. She represents clients across the U.S., including professional associations, managed care providers, hospitals, long-term care facilities, home health agencies, durable medical equipment companies, and hospices.

©2026 Elizabeth E. Hogue, Esq. All rights reserved.
No portion of this material may be reproduced in any form without the advance written permission of the author.

Medicaid Reform

Home Health

by Kristin Rowan | Apr 17, 2026 | Home Health, Medicaid, Regulatory, Waste Fraud and Abuse

by Kristin Rowan, Editor

Medicaid Reform

New Efforts to Stop Fraud Before it Happens

As auditors continue to investigate fraudulent activity, new initiatives through Medicare reform aim to stop fraud before it happens. The new initiative, the Combating Deceptive Practices in Assistance Programs Act adds oversight to the Medicaid program.

Preserve Medicaid through Reform

Chairman of the Joint Economic Committee and Chairman of the House Ways and Means Oversight Subcommittee, Rep. David Schweikert, announced the legislation that would tighten eligibility requirements for home health services through Medicaid. The bill requires Medicaid recipients to prove they are unable to perform three or more ADL’s without assistance.

If we seriously want to preserve Medicaid, and provide for the people most in need, we must crack down on fraud. Reaching people that need these services the most should be the top priority of these programs, not growing one of the largest jobs corps in the state. With the U.S. adding almost $87,000 per second to our national debt, making commonsense reforms can save tens of billions of dollars while protecting the truly vulnerable.”

Rep. David Schweikert

Chairman, Joint Economic Committee and House Ways and Means Oversight Subcommittee

Medicaid Waiver Programs

According to the statement from the Joint Economic Committee, the federal waiver programs that allow states to provide at home care for Medicaid beneficiaries are lacking guardrails and oversight. The state policies are “egregious” and lead to waste, fraud, and abuse.

For example, the New York State Medicaid program includes the Consumer Directed Personal Assistance Program (CDPAP) which allows beneficiaries to choose their caregiver. This broad eligibility program allows enrollees to choose friends or family members with no caregiving experience. New York’s Medicaid spending jumped from $2.5 billion in 2019 to more than $9 billion in 2023 with estimates of $12 billion in 2025.

More Information

Read H. R. 7713

Read the accompanying brief from the Joint Economic Committee: From Care to Cash: Correting Misaligned Incentives in Home Health

# # #

Kristin Rowan is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news. She is also a sought-after speaker on Artificial Intelligence, Technology Adoption and Lone Worker Safety. She is available to speak at state and national conferences as well as software user-group meetings.

Kristin also runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. She works with care at home software providers to create dynamic content that increases conversions for direct e-mail, social media, and websites. Connect with Kristin directly at kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2026 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

California Hospice Fraud

CMS

by Kristin Rowan | Apr 10, 2026 | CMS, Home Health, Hospice, Waste Fraud and Abuse

by Kristin Rowan, Editor

California Hospice Fraud

Update 04-16-2026

Reports continue of additional arrests and revoked licenses in the California Hospice Fraud investigations. The anti-fraud task force suspensions rose to 447 hospices and 23 home health agencies this week. The total estimated fraud is more than $600 million. A White House official said, “[the task force] is reviewing and pursuing every possible lead. These suspension numbers, and the dollar values saved, are only going to increase.” Dr. Oz has promised to investigate “every single hospice in California.”

Multiple Arrests and Charges

Hospice fraud has been under investigation with much scrutiny by CMS. National efforts against waste, fraud, and abuse have focused on states with high probability of defrauding the Medicare Trust Fund. On April 9, 2026, California Attorney General Rob Bonta announced charges filed against 21 suspects accused of defrauding the government of $267 million. Five people were arrested and two handguns and more than $750,000 in cash were seized.

Intent to Defraud

After a credible report of fraud, an investigation ensued. The investigation uncovered this scheme. Individuals bought personal identifying information (PII) from people not living in California. They bought the PII through the dark web. They then enrolled these “people” in Medi-Cal, the California Medicaid program. Straw owners purchased 14 hospice companies and started billing Medi-Cal for hospice services for the stolen identities without providing those services.

Location Search

As part of a separate hospice fraud investigation, agencies conducted compliance reviews at a single location in Van Nuys. The address is home to more than 125 individual businesses. Of those, only 19 are licensed by the state and eligible to bill Medi-Cal. 60 percent of the remaining 109 businesses applied for hospice licenses and were denied by the state based on the moratorium on new hospices in place in California since 2021.

The 71 Million Dollar Doctor

Dr. Rajiv Bhuva has connections to Medicare claims from 126 different hospices in California, 115 of which are in LA County. The claims are for almost 2,800 patients. The average doctor cares for 140 patients annually. Dr. Oz confirmed that CMS has revoked Dr. Bhuva’s ability to bill Medicare. Dr. Bhuva has not yet been charged with a crime. A similar case in 2024 resulted in the conviction of Dr. Domingo Barrientos on the charge of conspiracy to commit healthcare fraud. Dr. Barrientos is in federal prison.

Task Force Suspends Providers

A federal anti-fraud task force working in California is investigating both hospice and home health providers. The focus is currently on Los Angeles and LA County, where high numbers of new agencies raised suspicion. As efforts have ramped up, the task force reported suspending 70 providers last week and a staggering 221 total providers suspended so far. The task force anticipates dramatically higher numbers before they’re done. The operation has identified multiple defendants and hundreds of millions in fraudulent claims.

# # #

Kristin Rowan is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news. She is also a sought-after speaker on Artificial Intelligence, Technology Adoption and Lone Worker Safety. She is available to speak at state and national conferences as well as software user-group meetings.

Kristin also runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. She works with care at home software providers to create dynamic content that increases conversions for direct e-mail, social media, and websites. Connect with Kristin directly at kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2026 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

Fraud and Abuse Misunderstandings

Clinical

by Elizabeth E. Hogue, Esq. | Apr 3, 2026 | Clinical, Legal, Regulatory, Waste Fraud and Abuse

by Elizabeth E. Hogue, Esq.

Medicare and Medicaid Fraud and Abuse

Common Misunderstandings

Providers are generally familiar with prohibitions against fraud and abuse in the Medicare and Medicaid Programs, including Medicaid waiver programs, and other state and federal health care programs, such as the VA and TriCare. Private insurers now often enforce the same prohibitions applicable to federal and state programs. But there are at least two common misconceptions about fraud and abuse.

Intent

Enforcers must prove intent in order to show that providers engaged in fraud, but providers may not understand what the government can use to show “intent.”

Premeditation

Many providers seem to think that the only way to show intent is to prove that they sat down at their desks on a Monday morning and decided to commit fraud, but court decisions tell a very different story! They say that if enforcers can prove that providers knew or should have known of a pattern of fraudulent conduct, enforcers may conclude that providers had intent. Other court decisions say that when providers show reckless disregard for a pattern of fraudulent conduct regulators can show intent necessary to prove fraud.

When providers grasp these crucial standards, it is clear that they must become vigilant to prevent patterns of fraud and abuse. This is necessary in order to prevent government enforcers from concluding that they had intent necessary to prove fraud and/or abuse.

Personal Responsibility

Many providers also may not understand that every provider, regardless of position, is personally responsible for fraud and abuse compliance.

It Rests on You

It is extremely tempting to think that fraud and abuse compliance is management’s responsibility, or the exclusive job of the Administrator/Chief Executive Officer or the organization’s Compliance Officer. On the contrary, the Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services, the primary enforcer of fraud and abuse prohibitions, is quite clear that every practitioner has personal, individual responsibility for fraud and abuse compliance.

The problem of fraud and abuse will never be solved until every practitioner takes individual responsibility for it. Enforcement action is often taken against individual practitioners, as well as members of management and owners.

Complete Compliance

When providers understand these two basic points, they are well along the road to active participation in fraud and abuse compliance efforts.

Final Thoughts

Providers must remember that fraud and abuse compliance is now a permanent part of the health care landscape across the nation. Compliance is not a fad that will blow over or disappear! Providers must be prepared to actively work to prevent or correct fraud and abuse for as long as they work in the healthcare industry.

# # #

Elizabeth Hogue is an attorney in private practice with extensive experience in health care. She represents clients across the U.S., including professional associations, managed care providers, hospitals, long-term care facilities, home health agencies, durable medical equipment companies, and hospices.

©2026 Elizabeth E. Hogue, Esq. All rights reserved.
No portion of this material may be reproduced in any form without the advance written permission of the author.

Fraud and Abuse Compliance

Admin

by Elizabeth E. Hogue, Esq. | Dec 18, 2025 | Admin, Home Health, Hospice, Legal, Waste Fraud and Abuse

by Elizabeth E. Hogue, Esq.

Fraud and Abuse Compliance

Why All Providers Should Have One

Providers may have heard or read about the importance of Fraud and Abuse Compliance Programs in their organizations. Despite the wealth of available information about Compliance Programs, many providers continue to express uncertainty about their value.

Coincidentally, as we are preparing to publish this article, HHS publishes this report on the compliance audit of Guardian Home Care, LLC.

Here are some of the questions providers often ask about Compliance Programs:

Why should we have a Fraud and Abuse Compliance Program?

First

The Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS) has clearly stated that all providers are now required to have current Compliance Programs that are fully implemented.

As a practical matter, when providers establish and maintain Compliance Programs, it clearly discourages regulators from pursuing allegations of fraud and abuse violations. Jody Hunt, formerly of the DOJ, says providers should create robust fraud and abuse compliance programs. Then providers can argue that they shouldn’t be liable for violations because their compliance programs demonstrate that they had no intent to commit fraud.

Technically speaking, the Federal Sentencing Guidelines make it clear that establishment and implementation of Compliance Programs is considered to be a mitigating factor. That is, if accusations of criminal conduct are made, the consequences may be substantially less severe as a result of a fully implemented Compliance Program.

Additionally

Providers with Compliance Programs are more likely to avoid fraud and abuse. This is because Programs routinely establish an obligation on the part of every employee to report possible instances of fraud and abuse and include training for all employees.

Compliance Programs may also help to prevent qui tam or so-called “whistleblower” lawsuits by private individuals, rather than by government enforcers, who believe that they have identified instances of fraud and abuse. There are significant incentives to bring these legal actions since “whistleblowers” receive a share of monies recovered as a result of their efforts. Some “whistleblowers” have received millions of dollars. Compliance Programs make it clear that employees have an obligation to bring any potential fraud and abuse issues to the attention of their employers first.

Also…

The federal Affordable Care Act (ACA) requires providers to have Compliance Programs. In short, it’s the law!

Finally

The Deficit Reduction Act (DRA) requires providers who receive more than $5 million in monies from state Medicaid Programs per year to implement policies and procedures, provide education to employees and put information in their employee handbooks about fraud and abuse compliance. These requirements can be met through implementation of Fraud and Abuse Compliance Programs.

We don't receive reimbursement from the Medicare or Medicaid Programs.

Do we still need a Compliance Program?

Statutes and regulations governing fraud and abuse also apply to providers who receive payments from any federal and state healthcare programs, including Medicaid, Medicaid waiver and other federal and state health care programs, such as Tri-Care. Many private insurers have followed the federal government’s “lead” in terms of fraud and abuse enforcement. So private duty providers must have compliance programs, too.

Should we just use the model guidance that is applicable to us?

We hear that the OIG has provided guidance for various segments of the healthcare industry regarding Compliance Programs. Specifically, the OIG has already published guidance for clinical laboratories, hospitals, home health agencies, skilled nursing facilities (SMFs), hospices, physicians’ practices, third-party billing companies and home medical equipment companies. The OIG will publish updated guidance for all providers, It has already done so for SNFs.

The answer is “No!” Guidance from the OIG is not a model Compliance Program. Guidance from the OIG consists of general guidelines and does not constitute a valid Compliance Program. In addition, the OIG has made it clear that Programs must be customized for each organization.

Do we have to conduct internal audits first?

We have read that, before implementing Compliance Programs, providers must conduct expensive internal audits that can take many months to complete. Is this true?

While beginning the compliance process with an extensive internal audit is certainly one way to proceed, it is not the only viable way to work toward compliance. It is equally valid to begin with Compliance Programs that are customized for the organization that includes training for all employees about fraud and abuse and Compliance Programs. Then all staff members can subsequently participate in internal compliance activities, including audits, with a process in place to handle any issues that arise as a result of the audits.

We already have policies. Why do we need a Compliance Program too?

Compliance Programs are specific types of documents that routinely address issues that providers do not usually cover in internal policies and procedures. In addition, providers may not gain benefits under the Federal Sentencing Guidelines described in the first question above if there is no formal document called a Compliance Program.

We're accredited. Doesn't that mean we are in compliance?

On the contrary, Compliance Programs appropriately address potential fraud and abuse issues. They also include mechanisms for helping to ensure compliance such as processes for identification and correction of potential problems that are not addressed during the certification process. In other words, organizations may be accredited but fail to meet applicable compliance standards for fraud and abuse.

Will it help with investigations?

Will the fact that our organization has a Compliance Program make any difference with regard to the outcome of fraud and abuse investigations and the imposition of Corporate Integrity Agreements (CIA’s)?

Yes, it may make a considerable difference based on statements from the OIG. If providers have Compliance Programs in place that are current and fully implemented, the OIG may be less aggressive in pursuing potential violations. When the OIG actually discovers problems with fraud and abuse in organizations, providers are usually asked to develop and implement a Corporate Integrity Agreement (CIA). The OIG often requires CIA’s to include a process for stringent monitoring by the OIG on a continuous basis. These monitoring activities can be extremely burdensome to providers in terms of both time and money. Providers with valid Compliance Programs are not necessarily asked to develop and implement CIA’s.

Final Thoughts

Now is the time for all providers to recognize and act upon the need to establish and maintain Compliance Programs. “Working on it” is no longer good enough.

Elizabeth Hogue is an attorney in private practice with extensive experience in health care. She represents clients across the U.S., including professional associations, managed care providers, hospitals, long-term care facilities, home health agencies, durable medical equipment companies, and hospices.

No portion of this material may be reproduced in any form without the advance written permission of the author.

Can This New Software Eliminate Fraud and Billing Errors?

Admin

by Tim Rowan | Oct 9, 2025 | Admin, Medicaid, Product Review, Waste Fraud and Abuse

by Tim Rowan, Editor Emeritus

Software Eliminates Fraud and Errors

Like so many Home Care providers, Aspen Home Care in Kansas City, Missouri was drowning in paper. Two hundred caregivers turned in weekly timesheets every Friday. A large office staff had to go through them, looking for errors, omissions, and unauthorized visits and shifts. Submitting erroneous claims, of course, leads to payment denials, even fines. When an agency submits too many bad claims every week over a long period, a surveyor will soon be knocking at their door.

The Hurdles

On a good week, Aspen completed all necessary payroll and billing tasks and had bills ready to submit by end of business on the following Thursday. Slowing down the process were the usual errors — forgotten check-outs, more hours worked than authorized, and late timesheet submission. Caregivers grew weary of the weekly phone calls asking for clarification, even when the error was their fault. Aspen did have a basic billing system, but paper timesheets fed it too. Electronic Visit Verification was possible, but only via a patient’s landline, using punched-in identification codes.

Then... the call came

“After years of software design, we have completed our replacement for your billing and EVV system. We would like you to switch from the basic system we sold you a few years ago and beta test our better one.”

– Henry (Hank) Schwab, Owner, Compliance Plus

Beta testing is a risky venture, but both owner Ahmed Jara and Office Manager Mohammed Mohammed* trusted Hank and agreed to give it a try. After all, the agency was drowning in paper, they reminded each other.

Dramatic Process Improvements

We took part in a demo of the Compliance Plus system before speaking with Mohammed and hearing Aspen’s experience. We saw a comprehensive, user-friendly system, with a color-coded user interface, that includes scheduling, EVV, and billing for Medicaid, Managed Care, and all other payers an agency contracts with.

Time Tracking

Caregivers clock in and out with an app that is GPS-enabled down to exact longitude and latitude coordinates. Should a patient live in an internet dead zone, caregivers can use their landline. If there is no landline, Aspen will install a “smart fob” in the home. Aspen does not require specific visit start times, but once a check-in is recorded, the app knows the patient’s authorized hours and automatically alerts the caregiver when it is time to clock out.

Verification

Mistakes do happen, of course, but fixing them is not difficult. When the Compliance Plus back end sees a 14-hour visit, it assumes the caregiver forgot to check out. The visit flashes red on the screen, indicating it is not ready to bill, and displays the difference between authorized and recorded hours. The office employee managing exceptions simply calls the caregiver for verification and then manually edits the end time, and compliance is maintained.

Caregiver Feedback

Mohammed told us his caregiving staff is thrilled with the app, though he did say the transition was hard at first. “They learn to use it in about 30 minutes,” he said. “Check-in and check-in take a few seconds and now they are happy to be done with paper forever, not to mention no longer having to deliver paper timesheets to the office.” He added that fake check-ins from the car on the way to a patient’s home have been completely eliminated.

Most importantly, the three-person office staff now completes payroll and billing for 200 caregivers by midday on Tuesday instead of late on Thursday.

The "Plus" of Compliance Plus

Certainly, procedural efficiencies are important, and many scheduling and EVV systems force caregivers to check in and check out in the presence of the patient and alert office staff when a caregiver arrives late or is a no-show. What we saw during our demo, however, we have not seen elsewhere. Compliance Plus automates the tedious task of rooting out EVV, billing, and payroll errors so efficiently, payment denials, aggregator rejections, and incorrect paychecks are virtually eliminated.

Denials are Rare

Mohammed confirmed what we saw in the demo. The file that includes hours, authorizations, patient demographics, and pre-arranged pay rates is prepared and perfected in advance. Then, the system uploads the same corrected file to the aggregator and to state and other payers. “If we need to fix hours or a bill, we do it before uploading to all entities,” he said. “We rarely get rejections from the aggregator or denials from payers.”

Aggregated Data

One of the requirements of payers and EVV aggregators is that all patient and caregiver names and other information must be in their respective databases in advance. Compliance Plus finds missing data and removes a bill from the file before it is uploaded, notifying the user with a red flag. Mohammed added, “We have to make sure all patient data is in system, but that is easy to do.”

Implementation and Training

In every home care agency, there is always a measure of trepidation among the staff when switching from familiar paper to automation. Aspen Home Care was no different when owner Ahmed Jara announced that he had accepted Hank’s invitation to join a beta test. Mohammed told us that his staff’s time from implementation to software expertise took a little less than three months. Compliance Plus customer relationship manager Sara Moore conducted online training of key office staff, a service that is included in Aspen’s monthly fee. Mohammed and a couple others trained the rest of the staff on the full system and then caregivers on the use of the app.

“After a short while, the new system became our normal workflow,” Mohammed commented. “The only speed bump is when they upload new features. We need to spend a little time learning them, but ultimately, the new features improve our workflow. Our caregivers pick up the app in about 30 minutes, including new hires.”

Favorite Features

He added that his 200 caregivers like checking in and out on the app better than the legacy ANI system, which used the patient’s landline for automatic number identification. “English is a second language for some of our caregivers, and they sometimes had trouble with the ANI prompts spoken by the computerized voice,” he explained. “GPS verification is the best feature. If a caregiver checks in from too far away, we see their distance from the patient’s home on a map, and we gently ‘re-educated’ them and it does not happen again. In the past, they would sometimes get away with asking a family member to check in for them from the patient’s landline. Those days are gone.”

He also told us that Aspen does not insist on specific start times. What matters is that visit length matches authorized hours over a billing period. This is especially helpful for waiver and HCBS plans when the caregiver lives in the home. In those arrangements, checking in or out used to be easily forgotten. “I take care of her all day, how do I know when I start and stop?” The Compliance Plus app rings its cell phone loudly to remind visiting and live-in caregivers to check in and then to check out after the authorized number of hours have been reached.

Simplifying Complex Billing

Presently, Aspen exclusively serves Medicaid beneficiaries, though that can mean several managed care payers. With varying reimbursement rates from payers, combined with different caregiver hourly rates, getting a bill to match an authorization used to be a challenge for Office Manager Mohammed and his team.

It's Complicated

In the case of an agency employed family caregiver, there are often days when the family member will spend one hour toileting and feeding, the next hour doing reimbursable homemaking chores, and the third hour running care-related errands. Not only might those tasks be paid at different rates, but they can, and often are, reimbursed by different payers.

Patient Profiles

Mohammed emphasized that the way Compliance Plus handles these situations saves considerable time and reduces payer and aggregator rejections. Like in a Venn diagram, every combination of patient, payer, task type, and caregiver creates a “patient profile.” The user created most profiles in advance, based on known payer rates, etc. Occasionally, a patient’s profile is unique, but a user can easily enter the specifics into the system manually. Once a profile is built, the system calculates all of the billing accurately without additional user supervision.

Task Rates

If a payer’s rate for a task changes, Mohammed or another office staffer makes the change one time for all affected patients. In that scenario where the live-in caregiver performs three different tasks in one day, he or she checks in and out only once, before the first task and after the last, and designates each task performed. Compliance Plus does the rest.

Company Prospects

Hank Schwab told us that he is confident, after 100 successful beta customers, that Compliance Plus is ready for general release. At $10 to $12 per patient per month, he believes that supplementing word-of-mouth with a modest marketing effort will help him replace paper and strengthen the bottom line for many Medicaid and Personal Care agencies. Hank’s plan is to begin that effort as soon as he identifies an investor or two and hires a marketing director. “I already manage a team of coders and personally pay all the bills,” he laughed. “I’m ready for someone else to take on a few of my jobs.”
https://complianceplus.com/

# # #

Tim Rowan is a 30-year home care technology consultant who co-founded and served as Editor and principal writer of this publication for 25 years. He continues to occasionally contribute news and analysis articles under The Rowan Report’s new ownership. He also continues to work part-time as a Home Care recruiting and retention consultant. More information: RowanResources.com
Tim@RowanResources.com

©2025 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

Fraud, Waste, and Abuse

Clinical

by Kristin Rowan | Jul 10, 2025 | Clinical, CMS, Home Health, Legal, Medicare, Medicare Advantage, Regulatory, Waste Fraud and Abuse

by Kristin Rowan, Editor

Fraud, Waste, and Abuse

DOJ, HHS False Claims Act

Fraud, Waste, and Abuse has become something of a mantra within the Department of Health and Human Services (HHS). Secretary Kennedy has committed to combatting fraud, waste, and abuse within the federal healthcare system. The Department of Justice (DOJ) and HHS have a long history of working together to combat healthcare frauding under the False Claims Act (FCA).

Working Group

In furtherance of their goal to combat healthcare fraud, HHS and DOJ have formed the DOJ-HHS False Claims Act Working Group. The Working Group will include leadership from the HHS Office of General Counsel, CMS Center for Program Integrity, the Office of Counsel for the OIG, and the DOJ Civil Division.

Working Group Priorities to Combat Fraud, Waste, and Abuse

1. HHS will refer potential False Claims Act violations to the DOJ that are in line with the Working Group priority enforcement areas:

Medicare Advantage
Drug, device, or biologics pricing
- arrangements for discounts, rebates, service fees, and formulary placement and pricing reporting
Barriers to patient access to care
- violations of network adequacy requirements
Kickbacks related to drugs, medical decives, DME, and other products paid for by federal healthcare programs
Materially defective medical devices that impact patient safety
Manipulation of Electronic Health Records systems to drive inappropriate utilization of Medicare covered products and services

2. The Working Group will maximize collaboration to expedite investigations and identify new leads. They will leverage HHS resources using data mining and assessment of findings.

3. The Working Group will discuss implementing payment suspension according to the CMS Medicare Program Code of Federal Regulations¹

4. The Working Group will discuss whether DOJ will dismiss a whistleblower case under the U.S. Code for Civil actions for False Claims, pursuant to the DOJ Manual for Civil Fraud Litigation²

Report Fraud, Waste, and Abuse

The Working Group encourages whistleblowers to report violations of the False Claims Act within the priority areas. Tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement can be reported to HHS at 800-HHS-TIPS (800-447-8477). Similarly, the Working Group encourages healthcare companies to identify and report such violations.

²DOJ Dismissal of a Civil Qui Tam Action. When evaluating a recommendation to decline intervention in a qui tam action, attorneys should also consider whether the government’s interests are served, in addition, by seeking dismissal pursuant to 31 U.S.C. § 3730(c)(2)(A).

¹Suspension of payment. The withholding of payment by a Medicare contractor from a provider or supplier of an approved Medicare payment amount before a determination of the amount of the overpayment exists, or until the resolution of an investigation of a credible allegation of fraud.

# # #

Kristin Rowan has been working at The Rowan Report since 2008. She is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news, and speaker on Artificial Intelligence and Lone Worker Safety and state and national conferences.

She also runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2025 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

Fraudsters Arrested, Oz Issues Warning

CMS

by Kristin Rowan | Jun 6, 2025 | CMS, Hospice, Medicaid, Medicare, Medicare Advantage, Regulatory, Waste Fraud and Abuse

by Kristin Rowan, Editor

Fraudsters Arrested, Oz Issues Warning

Fraud in California

Fraudsters arrested in West Covina, CA this week were allegedly running a Medicare scheme. Authorities arrested hospice owner-operator Normita Sierra. They charged her with nine counts of health care fraud, one count of conspiracy, and four counts illegal remuneration (kick-backs) for health care referrals. The U.S. Attorney’s Office named co-conspirator Rowena Elegado. They also arrested her and charged her with one count of conspiracy and four counts of illegal remuneration for health care referrals.

Kickbacks

Sierra and Elegado worked together to pay marketers to recruit patients who did not have a hospice referral from their PCP and who were not terminally ill. Some of the kickbacks paid to marketers were as high as $1,300 per patient per month. After six months, the patients were referred out to Sierra’s home health company.

Medicare Claims

According to the U.S. Attorney’s Office, from 2018 to 2022, Sierra’s hospice agences submitted $4.8 million in fraudulent claims. Of those claims, Medicare paid approximately $3.8 million.

Dr. Oz Issues Warning

In a video statement, Dr. Oz explained how Medicare recipients are falling victim to scams. Sales people call, email, and even knock on your door, offering advice, free samples, and referrals. These marketers have one goal: get you sign a piece of paper. That paper signs you up for hospice care and agrees to allow a specific hospice agency to provide that care. The hospice agency then bills Medicare for services they never provide. Watch the video statement here.

HHS OIG Issues Consumer Alert

In a similar statement, HHS issued a consumer alert regarding DME companies. The alert warns that some DME companies are contacting Medicare beneficiaries. They claim to work for or on behalf of Medicare. Once they receive the patient’s Medicare number, they bill Medicare for unnecessary medical items. These items include urinary catheters, knee and back braces, orthotic braces, and prescription drugs, which may or may not ever be sent to the patient. HHS urges enrollees not to give their Medicare number to anyone. Further, they suggest regulary reviewing items charged to insurance, and refusing delivery of any medical supply not ordered by a physician.

Combating Waste, Fraud, and Abuse

Dr. Oz and CMS have spoken numerous times about combatting the waste, fraud, and abuse withing the Medicare and Medicaid systems. Originally a strong proponent for Medicare Advantage, Oz has promised to audit MA after discovering the government pays more for MA than traditional Medicare. Oz also promised to reduce the amount of prior authorization requests needed before a patient gets services. Oz responded to the Republican-backed House bill requiring more oversight on Medicaid eligibility. Oz indicated that some Medicaid patients are enrolled in more than one state and that Medicaid is paying for able-bodied patients. The waste, fraud and abuse across Medicare and Medicaid is costing the government between $1 and $10 billion and Dr. Oz plans to find it and make significant changes to the management of the system.

A Cautionary Tale for Hospice Providers

You may be thinking, “What does this have to do with me?” Unfortunately, even the most scrupulous hospice agencies can fall prey to marketers running schemes. There are legitimate referral resources in the market who can help your agency get more referrals and more clients. There are also underhanded marketers who know how the system works. These predators will promise new referrals (for a fee) and then enroll uneligible patients without your knowledge. If you are working with or looking for a referral partner for your hospice agency, use one that is referred by someone you trust, and/or do a lot of research on the company history before working with anyone. Be especially wary of the ones who promise much more than what most referral companies offer.

# # #

Kristin Rowan has been working at The Rowan Report since 2008. She is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news, and speaker on Artificial Intelligence and Lone Worker Safety and state and national conferences.

She also runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2025 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com