Strengthening Home Health Fraud Prevention
with Exclusion Monitoring That Actually Works
As scrutiny of fraud, waste, and abuse in healthcare reaches new heights, all eyes are on home health organizations.
The Department of Justice reported a record-breaking $5.7 billion in False Claims Act settlements and judgments in the healthcare sector in FY 2025 alone, and lawmakers continue to call for increased oversight of home health agencies in particular.
It’s no secret that fraud is a persistent issue in the home health industry. In fact, Medicaid Fraud Control Units (MFCUs) regularly report that Personal Care Services (PCS) attendants make up about 3 times as many fraud convictions as any other provider category. And because home health care is delivered in silos to patients who are often especially vulnerable, it can be quite difficult to detect fraud, waste, and abuse until it’s already happened.
To Prevent Fraud, Go Back to the Basics
The prevalence of fraud in home health makes it even more important for these organizations to lean on fraud prevention tools, including a comprehensive exclusion monitoring solution, especially given the sheer volume of Medicare and/or Medicaid funds that go towards home health organizations.
There are 50+ primary sources that contain more than 280,000 federal and state exclusions, and the primary sources have varying levels of data completeness. It also takes an average of 420 days for a state exclusion to make it onto the Office of the Inspector General’s List of Excluded Individuals and Entities (OIG LEIE), leaving a large gap in time where an exclusion can go undetected.
Here’s the problem: Most automated exclusion monitoring solutions accept the data from each primary source at face value, and not all provider organizations monitor every state list in addition to the federal lists. So, a PCS attendant could be excluded in Alabama, but if they start working in Georgia, that exclusion could go totally unnoticed by their employer.
The only way to prevent these gaps in visibility is to connect the data from each primary source—state and federal—into a comprehensive, verified dataset. That’s exactly what ProviderTrust has spent the past 15-plus years doing.
How Data Enrichment Bridges the Gap
ProviderTrust’s data enrichment strategy takes a simple approach to the complex problem of disjointed primary sources. We can’t control the disconnected nature of the primary sources, but we can control how we ingest the primary source data and reflect it back to our clients.
Instead of automated, siloed searches of each individual primary source, we’ve aggregated (and verified) the data from each primary source and added unique data points to create our own dataset. This dataset is regularly cleansed, updated, and improved to ensure that it’s always up to date. Importantly, it’s also validated and refined by our expert data oversight team, so our clients get the best of both worlds: sophisticated automation and human governance.
This means that ProviderTrust data is actually better than the primary source, because it contains the full context of each primary source, rather than just one. Because of data enrichment, ProviderTrust clients don’t have to wonder if their employees have simply moved states or changed their names to avoid detection.
Data Enrichment in Action
Our data enrichment strategy benefits all ProviderTrust clients, but our home health clients see an even greater return on their investment in exclusion monitoring. On average, about 46% of the 52,783 exclusions we’ve identified for all clients over the past 15 years could only be found with our enriched data.
When you zoom in on the home health sector, data enrichment plays an even bigger role in catching exclusions that no one else can. Consider these three case studies:
CLIENT A
A nationwide home health organization with a population of 34,200 care providers serving more than 200,000 patients each year.
Total exclusions found:
Exclusions found only with enriched data:
of this client’s exclusions were found with enriched data
CLIENT B
A nationwide home health organization with a population of 22,600 care providers serving about 500,000 patients each year.
Total exclusions found:
Exclusions found only with enriched data:
of this client’s exclusions were found with enriched data
CLIENT C
An enterprise home health organization with a population of 16,800 care providers across 38 states.
Total exclusions found:
Exclusions found only with enriched data:
of this client’s exclusions were found with enriched data
These three clients represent a larger trend within home health: traditional exclusion monitoring just isn’t good enough anymore. Data enrichment doesn’t just acknowledge the gaps in standard exclusion monitoring—it bridges those gaps and provides all the context that ProviderTrust clients need to make the crucial decisions about who provides care for their patients.
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