Assurance · Pennsylvania Medicaid · Home Care Fraud Prevention

Stopping home care fraud before Pennsylvania Medicaid pays for it.

A pre-payment prevention and post-payment forensic audit system, purpose-built for the Special Investigation Units of Pennsylvania Medicaid MCOs.

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The Problem

This isn't hypothetical — it's already been prosecuted.

In August 2026, DOJ's Eastern District of Pennsylvania and a national Medicaid Fraud Strike Force announced coordinated charges for over $5.76 million in fraudulent Pennsylvania Medicaid home care billings.

Named patterns included a caregiver who billed 64,000+ physically impossible hours, another with 8,700+ overlapping billed hours, billing during a client's incarceration or hospitalization, falsified EVV records, and kickbacks paid to clients to sign off on hours never worked.

Four of the five billing patterns named in that case are live in Assurance today — the fifth is already scoped for the next phase.

Source: DOJ Eastern District of PA, "Dozens Charged With Health Care Fraud… Involving $5.76 Million in Billings to Pennsylvania's Medicaid Program," Aug. 4, 2026 (justice.gov/usao-edpa).

$5.76M
In fraudulent PA Medicaid home care billings named in a single coordinated enforcement action
64,000+
Physically impossible hours billed by one caregiver in the DOJ case
8,700+
Overlapping billed hours from a second caregiver named in the case
$5.6B+
Estimated annual PA Medicaid spend on personal-assistance/home-care services statewide

Market-sizing estimate: PA DHS FY2024-25 Blue Book; CareRing Health PAS Rate Study for the PA Homecare Association. Conservative, directional estimate — see full sourcing notes available on request.

Why Nothing Else Catches This

Everyone else is looking at one piece of the picture. An MCO sees the whole thing.

State EVV Aggregators

State-mandated EVV platforms verify that a visit happened — they don't detect fraud patterns across visits, caregivers, or agencies.

Agency Scheduling Software

Agency-level scheduling and billing tools only see one agency's own data, so they structurally cannot see a caregiver double-billing across two different agencies.

General Fraud Analytics

Broad healthcare fraud analytics platforms are built to cover claims across all of healthcare — not tuned to home care's specific fraud signatures.

The Platform

24 fraud detection modules, built from real enforcement cases and a decade inside the industry.

Built and tested on a fully synthetic, fictitious 90-day dataset (88 caregivers, 29 clients, 5,141 shifts).

22 / 24
Modules live today, spanning both pre-payment prevention and post-payment forensic audit
2
Additional modules scoped and ready to build once a data-sharing agreement is signed

Every module traces to one of three sources: DOJ's Eastern District of PA enforcement action (Aug. 4, 2026), CMS's "Vulnerabilities and Mitigation Strategies in Medicaid Personal Care Services," or a decade operating a PA home care agency from the inside.

Built to grow beyond Pennsylvania. The fraud patterns these modules catch aren't unique to Pennsylvania's billing system — they trace to federal DOJ enforcement patterns and CMS's own national Medicaid personal-care vulnerability research. The underlying detection logic adapts to any state Medicaid MCO's claims, EVV, and billing data.

Module-by-module detail — exact triggers, thresholds, and detection logic — is reserved for direct conversations with MCO SIU teams.

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Let's Talk

A conversation, then a partnership.

If you're with a Pennsylvania Medicaid MCO's Special Investigations Unit, I'd like to set up a conversation — one that starts with your team's priorities, and works from there to figure out together which fraud modules make the most sense to build next. Ultimately, what I want is a genuine partnership with one Pennsylvania MCO, working together to reduce fraud across the home care industry.

Email [email protected]

Assurance is currently in early conversations with Pennsylvania Medicaid MCOs and is not yet in production with any payer.