The Answer to Home Healthcare Fraud Isn’t More Bureaucracy

Every day, Americans across the country are providing in-home care for their aging parents, children with disabilities, or medically complex loved ones. Medicaid-funded caregiver programs are an essential part of making that possible for these thousands of families, providing critical support while addressing growing workforce shortages.

Unfortunately, bad actors are able to exploit these programs through fraud and abuse; the consequences extend far beyond wasted taxpayer dollars. Washington is right to take the growing problem of fraud in home healthcare seriously. Earlier this month, Senator Susan Collins introduced legislation designed to give CMS additional tools to identify high-risk home health providers and stop fraudulent payments before they are made. The proposal comes after CMS took the extraordinary step of imposing a six-month moratorium in May on new home healthcare providers, following federal enforcement officers uncovering healthcare fraud schemes.

These actions reflect a real problem. But as policymakers consider what comes next, we need to be equally focused on how we fight fraud, because how we do it will land squarely on real people and their families. As the founder of a company empowering family caregivers to provide care at home, I’ve talked with hundreds of caregivers of aging loved ones or medically complex needs. I’ve heard directly about the gaps in our health system: confusing eligibility rules and a mounting stack of paperwork, a sense that the system wasn’t built with them in mind.

More bureaucracy is not the key to greater transparency. It risks making it harder for legitimate providers to operate and for families to access care, pushing more people toward higher-cost institutional care when home-based care would serve them better. We have an opportunity to build smarter systems that identify risk earlier, focus scrutiny where it belongs, and make it easier for legitimate caregivers to comply with program requirements.

Technology and AI offer a better path forward. Instead of a system built to catch bad actors or problems after the fact, AI lets us build one that stops them before they ever enter the system. Take something as routine as documentation. Before a caregiver can begin providing authorized care, organizations may need to collect and validate numerous records against program specific requirements. Today, that work falls to employees who manually comb through documents, chase down missing information, and go back and forth with families to fix errors, one form at a time.

At Abby Care, we began exploring whether AI could make that process more efficient and more accurate. Our platform can compare certain submitted documents against program requirements, flag missing or inconsistent information, and surface issues early, before care begins. Routine, low-risk documentation gets handled efficiently, while consequential decisions stay with trained human reviewers. By combining real-time care documentation, digital audit trails, and clinical oversight, these tools create a more transparent record of care delivery, one that gives families, payers, and regulators greater confidence in the integrity of the care being provided.

Leveraging modern technology to enhance something like documentation protects everyone involved. Government regulatory agencies are already adopting similar technology-enabled approaches. For example, the CMS Audit Enforcement and Risk Oversight Initiative is using AI to examine over five years of audits from state and other federal grant recipients.

These tools can help identify unusual behavior across enormous datasets that would be difficult for individual investigators to detect manually. Meanwhile, states like Arizona are launching advanced analytics tools to detect suspicious billing patterns and strengthen program integrity.

However, using AI to combat fraud cannot mean removing human judgment from consequential healthcare decisions. Organizations should calibrate automation to the risks of error, keep high-consequence decisions subject to human judgment, and ensure systems are monitored for accuracy, bias, and unexpected failures. These safeguards are particularly important in Medicaid, where an administrative mistake can affect whether a family receives critical support.

As home healthcare grows, the current scrutiny of the industry presents policymakers with a choice. We can respond to fraud by making an already complicated system even harder to navigate, leaving families with no option but costlier institutional care and straining a healthcare system already stretched thin. Or we can build a more modern system that uses technology to distinguish risk, strengthen accountability, and concentrate human oversight where it is needed most.

Fraud undermines public trust and diverts resources away from people who genuinely need care. Fighting it aggressively is essential. Policymakers should support the use of AI and technology to prevent fraud before it enters the system and help restore trust in a sector that millions of families rely on every day.

Havi Nguyen is the founder and CEO of Abby Care