Home Care, Under Scrutiny

In Washington, the language is familiar: waste, fraud, abuse. The latest round of federal inquiry into Medicaid spending has reached Massachusetts again, with lawmakers pressing states to account for how they oversee billions in public dollars tied to care for older adults, people with disabilities, and low-income residents.

For those working inside the home care system, the headlines land differently.

Yes, there are bad actors. A recent Massachusetts case—where services were billed but never delivered—underscores that reality.  But to stop there is to miss the broader story: a growing, essential sector now carrying more responsibility than ever, under a level of scrutiny that is only intensifying.

Home-based care has become a cornerstone of the healthcare system, not a side door. Hospitals discharge patients earlier. Families shoulder more. The state leans on agencies to provide complex care in kitchens, bedrooms, and living rooms across Massachusetts. It is intimate work, often invisible, and increasingly indispensable.

And yet, the system that supports it is showing strain.

Federal investigators are not just asking whether fraud exists—they are asking whether states are doing enough to prevent it. That distinction matters. It signals a shift from reactive enforcement to proactive accountability. States, in turn, will look to providers.

For agencies, that means something simple and difficult at the same time: proving, consistently, that care delivered matches care billed.

Documentation, once treated as administrative burden, is now frontline defense. Electronic visit verification systems, care plans, supervisory visits—these are no longer compliance checkboxes. They are evidence. And in a climate where a single case can shape policy, evidence matters.

But there is tension here.

Every new layer of oversight carries a cost. Time spent documenting is time not spent caregiving. Smaller agencies, already navigating workforce shortages and thin margins, feel this most acutely. The risk is not just that fraud is caught—it is that legitimate providers are squeezed by the very systems designed to protect the program.

This is where the conversation needs to sharpen.

Fraud should be rooted out. Few would argue otherwise. It diverts resources from patients, undermines trust, and weakens the system. Lawmakers are right to pursue it.

But enforcement alone will not stabilize home care.

What’s required is balance: strong oversight paired with practical, informed policy that reflects how care is actually delivered in the home. That means engaging providers, understanding operational realities, and avoiding one-size-fits-all solutions that risk doing more harm than good.

Massachusetts has an opportunity here. The state’s home care network is experienced, deeply connected to its communities, and—by and large—committed to doing this work the right way. With the right support, it can meet higher standards without losing ground.

The alternative is a system that becomes harder to navigate, harder to sustain, and ultimately harder for patients to access.

The scrutiny is not going away. Nor should it.

But as the lens tightens, the focus must stay where it belongs: on ensuring that the people who depend on care at home receive it—reliably, safely, and with integrity.

Why This Matters Now

Earlier this month, Republicans on the U.S. House of Representatives Energy and Commerce Committee issued a press release regarding the committee's efforts to combat fraud within State Medicaid programs across the country. The committee sent letters to 10 states across the country, including Massachusetts, citing cases of fraud in recent years. The letters requested each state to respond to the committee by mid-March. 

Recent cases cited by federal investigators highlight significant abuse across states, including a Massachusetts case involving fraudulent billing for services that were never provided.

At a national level, lawmakers are signaling two things clearly:

• Enforcement will increase
• States will be expected to demonstrate stronger oversight

For agencies participating in MassHealth programs—or considering it—this raises the bar.

Earlier this week, MassHealth submitted a 41-page letter in response to the committee. In its letter, MassHealth outlined its expansive program integrity mechanisms which occur on a proactive basis and retroactive basis. MassHealth cites its close partnership with the Massachusetts Attorneys Generals Office to prosecute these crimes.

What This Means for Massachusetts Providers

It is unclear what the Committee will do next with these responses, but the Trump Administration has targeted state Medicaid programs in Minnesota and California. As this administration has been public with its intent to root out fraud and improve program integrity, the Home Care Alliance will be tracking this issue closely and work in partnership with the National Association for Care at Home. 

1. More Documentation Expectations
Clear, consistent, and defensible documentation of services provided will be essential. Gaps—even unintentional—can raise red flags.

2. Heightened Audit Activity
States may increase audits, reviews, and data analysis to identify irregular billing patterns.

3. Tighter Enrollment and Oversight Standards
Expect continued evolution in provider enrollment requirements, credentialing, and ongoing compliance monitoring.

4. Increased Focus on Program Integrity Systems
Electronic visit verification (EVV), care plans, and service authorizations will continue to be key tools in demonstrating compliance.

The Bigger Picture

Fraud cases—while not representative of the field—have outsized impact:

• They divert resources from legitimate providers and patients
• They increase regulatory burden across the board
• They shape public and legislative perception of home-based care

Federal leaders have made it clear that protecting Medicaid is both a fiscal and moral priority, particularly for vulnerable populations who rely on these services.

What Agencies Should Be Doing Now

This is a moment for proactive alignment—not reaction.

Strengthen internal controls

• Regular chart audits
• Billing reviews tied to documentation
• Clear supervisory oversight

Reinforce staff training

• Documentation standards
• Ethical billing practices
• Patient eligibility and consent

Evaluate systems

• Are your EVV and documentation systems audit-ready?
• Can you clearly demonstrate services delivered?

Stay connected

• Regulatory updates are evolving quickly
• Peer discussion and shared best practices are critical

Final Takeaway

This is not about isolated bad actors—it’s about a system under review.

Massachusetts agencies that prioritize transparency, strong processes, and compliance will be best positioned—not just to withstand scrutiny, but to lead.

As oversight increases, so does the opportunity to demonstrate the value, integrity, and essential role of home-based care.