HCAOA Encourages CMS to Take Targeted Approach to Fraud Enforcement

HCAOA ​submitted formal comments to the Centers for Medicare & Medicaid Services March 30 in response to its Request for Information on its CRUSH initiative — short for Comprehensive Regulations to Uncover Suspicious Healthcare — which seeks public input on new regulations to combat fraud, waste, and abuse in federal health care programs.

HCAOA's comments urged CMS to ground any new regulatory framework in empirical data and calibrate enforcement to demonstrated risk, rather than applying uniform requirements across all provider types. Our key points:

• Risk stratification: CMS' own data shows improper payments are concentrated in complex billing environments. HCAOA argued home- and community-based services present lower risk due to simpler billing structures and lower per-beneficiary expenditures.
• Existing safeguards: Agency-based providers already operate within auditable frameworks, including W-2 employment records, care plans and Electronic Visit Verification (EVV) systems that capture real-time service data.
• Documentation vs. fraud: Approximately 82 percent of Medicaid improper payments stem from insufficient documentation rather than intentional misconduct, according to CMS data cited in the comments.
• Access to care: HCAOA cautioned that additional administrative burdens could discourage provider participation in Medicaid at a time when demand for home care workers is projected to grow 17 percent through 2034.

The comments also offered five recommendations:

1. Standardize EVV across states.
2. Improve federal-state data sharing.
3. Expand provider education and technical assistance on billing compliance and documentation.
4. Use existing data sources for outlier detection.
5. Engage directly with the home care sector when creating and refining program integrity policies.

Read the full comments for more details.