Mehmet Ounces, the Facilities for Medicare & Medicaid Products and services administrator, is ordering all states to step up their efforts to crack down on Medicaid fraud.
His April 21, 2026, announcement expanded at the Trump management’s comparable enforcement movements, equivalent to withholding Medicaid finances from Minnesota and perilous to try this for New York, California and Maine.
The Trump management says there’s a large downside with fraud tied to government-funded care delivered in an individual’s domestic or locally, formally referred to as domestic and community-based services and products, together with nonmedical transportation, behavioral well being and new or excessive billing suppliers.
The company Ounces leads is now asking states to straight away “revalidate” suppliers they declare are “high risk.” This is, states are meant to require suppliers to end up that they continue to be eligible to take part in Medicaid and invoice this system. The suppliers basically be offering at-home care, transportation, behavioral well being and different services and products.
Comparable legislative projects, subsidized through Republicans, also are pending in Congress.
We’re well being services and products researchers who learn about the improvement and enlargement of the Medicaid domestic and community-based services and products program. One in all us (Barkoff) prior to now served within the function of administrator and assistant secretary for ageing of the Management for Group Residing.
We strongly consider that it’s good and essential for the federal government to take steps to forestall, root out and punish Medicaid fraud. However we’re conscious that the federal government’s anti-fraud methods and ways may just unnecessarily disrupt the very services and products that individuals rely on daily.
We aren’t on my own. Many researchers, advocates and coverage mavens are alarmed through this White Space coverage.
What’s at stake
All instructed, Medicaid supplies medical insurance protection for approximately 75 million low-income American citizens, together with many who’re a minimum of 65 years outdated.
Greater than 5 million American citizens have the benefit of government-funded domestic care, which is geared toward conserving low-income folks with disabilities and frail older folks residing in their very own properties and communities. Medicaid will pay for many domestic care, protecting just about two-thirds of all such spending in 2023.
When domestic care works neatly, folks change into much less prone to have to transport into nursing properties or different assisted residing amenities. If a house care aide doesn’t display up, the effects are speedy and may also be dire.
An older grownup could also be not able to get off the bed. An individual with disabilities might leave out foods or medicines. A circle of relatives caregiver can have to take day without work with out notifying their employer prematurely and lose wages.
That’s why the government’s movements – specifically the ones focused on services and products equipped in an individual’s domestic or network – may just endanger thousands and thousands of folks.
Via serving to low-income older folks pay for domestic well being aides, Medicaid makes it conceivable for lots of American citizens to stick in their very own apartments as a substitute of getting to relocate to a pro care facility.
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Excellent Courtroom ruling
House and community-based services and products come with lend a hand with bathing, dressing, consuming, medicine control and mobility – services and products that let folks to stay of their properties quite than shifting into nursing amenities. A shift towards home-based care has been underway for many years, pushed through each prices and civil rights protections.
One explanation why for the shift used to be the 6-3 ruling in 1999 through the Excellent Courtroom within the Olmstead v. L.C. case. The bulk affirmed the correct of folks with disabilities to are living in their very own properties and communities when conceivable.
Lately, maximum Medicaid long-term care spending covers the price of services and products equipped in an individual’s domestic or local people, quite than in an establishment. Those services and products value much less and result in higher results. Analysis and program information persistently display that fraud in those techniques is reasonably uncommon.
That is very true because of safeguards like digital seek advice from verification, which guarantees suppliers are in truth offering services and products in the house.
Some other safeguard in position is that almost all states contract with and approve
fiscal intermediaries, which act as payroll, cost and compliance managers, to ensure that there are verifiable information, cost controls and audit trails in position for the Medicaid program.
No longer all ‘improper payments’ are fraudulent
A central downside within the Trump management’s solution to root out alleged Medicaid fraud is a fundamental mischaracterization of many stuff as fraud that aren’t fraudulent.
Federal companies are monitoring “improper payments” and incorrectly equating them with fraud. The Facilities for Medicare & Medicaid Products and services makes transparent that almost all fallacious bills stem from documentation mistakes or administrative problems – now not intentional wrongdoing.
The Executive Duty Place of work, a nonpartisan authorities company that produces in-depth analysis, notes that whilst fraud does result in fallacious bills, the opposite isn’t essentially true. This is, fallacious bills could have a motive but even so fraud, equivalent to administrative mistakes and eligibility processing errors.
Blurring the dignity between fallacious bills and fraud could make it look like suppliers are illegally profiting from the gadget. And when that occurs, policymakers might flip to blunt answers that do little to punish exact fraudsters, equivalent to slicing or withholding investment, quite than solving administrative issues.
Exaggerating the scope of Medicaid fraud
In our view, proposals to overtake Medicaid’s enforcement strategies must be grounded in sturdy and function information. But a lot of the argument for structural reform depends on anecdotal examples, remoted instances and make a choice audit findings with out broader context.
Probably the most extra egregious instances perpetrated through suppliers used to be a house care company in Pennsylvania that billed fraudulent claims between 2020-2023 totaling US$1.8 million. Some other used to be the Minnesota supplier penalized in 2025 after billing for services and products now not delivered.
However the ones infractions don’t justify characterizing a whole class of services and products that is helping tens of thousands and thousands of American citizens stay of their properties as rife with fraud and short of dramatic adjustments.
Against this, as we defined in Well being Affairs ForeFront in March 2026, federal oversight our bodies – together with the Facilities for Medicare & Medicaid Products and services, the Executive Duty Place of work and the Well being and Human Products and services’ inspector normal – produce systematic, data-driven analyses.
Those assets persistently warning towards equating fallacious bills with fraud and emphasize focused approaches to program integrity.
The federal government designated some 6% of the once a year bills through Medicaid as fallacious bills between 2022-2025, which have been price about $37 billion. But, greater than 3 in 4 fallacious bills resulted from inadequate documentation, which most often doesn’t point out fraud or abuse.
What’s extra, Medicaid fraud is often matter to enforcement movements. In 2025, Medicaid fraud keep watch over gadgets reported 1,185 convictions for fraud national, and blended recoveries from prison and civil instances totaled about $2 billion.
Emphasis on high-profile instances
Once more, a couple of extensively publicized fraud instances in Minnesota and a couple of different states don’t end up that fraud is a prolonged downside for Medicaid billing in domestic care techniques.
In an company as giant as Medicaid, which spends just about $1 trillion every year, some degree of fraud will happen. The important thing query is whether or not fraud is common, systemic or is going unpunished.
To be had proof suggests Medicaid fraud is none of the ones issues.
For instance, large-scale domestic care techniques serving masses of 1000’s of folks document extraordinarily low charges of showed fraud instances. Enforcement information from Medicaid Fraud Keep an eye on Gadgets, which examine and prosecute Medicaid fraud, display that after fraud happens, it’s investigated and prosecuted.
In different phrases, the presence of enforcement process is proof that oversight techniques are running – now not that they’re failing.
A greater means
We consider that many methods which are higher than those who the Trump management is embracing are readily to be had. Some examples come with stepped forward information analytics, more potent referral techniques inside controlled care plans, enhanced supplier screening and documentation requirements, and persisted strengthen for Medicaid Fraud Keep an eye on Gadgets.
Those approaches goal fraud at once with out jeopardizing get entry to to the crucial Medicaid services and products that lend a hand tens of thousands and thousands of older adults and disabled folks stay the place they need to be: in their very own properties as a substitute of in costlier nursing properties.
For the reason that the U.S. spends about $930 billion a 12 months at the program, we don’t query the knowledge of attractive in its oversight.
However we’re involved that the coverage reaction to alleged fraud may just hurt the very those who the Trump management says its efforts are intended to give protection to.
