Home Care Fraud, Waste and Abuse: Australia’s Lessons for the U.S.
How US Providers and Policymakers Can Strengthen Payment Integrity While Preserving Access to Care
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2026年10月28日
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Key Takeaway: Australia’s home care model offers U.S. providers and policymakers a practical lesson: Strengthen payment integrity through accountable providers, coordinated care and transparent billing that helps consumers flag irregularities, while preserving access to essential services.
Introduction
As U.S. federal scrutiny of publicly funded healthcare intensifies, Australia offers practical lessons on providing access to personal care services for people who need them and strengthening payment integrity without making care harder to access.
Over the past 24 months, fraud, waste and abuse (‘FWA’) in publicly sponsored healthcare programs has moved to the center of the U.S. policy agenda.1 Personal care, home health, hospice and adult day care providers are under particular scrutiny. The enforcement signals are clear. The United States Department of Justice (‘DOJ’) and Centers for Medicare & Medicaid Services (‘CMS’) national fraud takedowns in both 2024 and 2025 included home health, hospice, personal care, and durable medical equipment providers. In February 2025, a California man pleaded guilty to healthcare fraud, aggravated identity theft, and money laundering in connection with more than $17 million in Medicare fraud through sham hospice companies and a home healthcare company.2 In August 2026, the DOJ announced charges against 19 defendants in alleged home care schemes involving more than $4 million in Medicare and Medicaid claims.3 The same announcement noted that federal healthcare strike forces have prosecuted more than 6,200 defendants associated with more than $45 billion in billings.4 And, in September 2026, Zakia Khan was sentenced to 76 months in prison in connection with her leadership role in carrying out a $64 million Medicaid fraud and illegal kickback scheme at two adult daycare centers and a home healthcare company.5
Australia has taken a different approach to delivering home care. For example, every Australian senior is eligible for a minimum threshold of home-based care paid for on a sliding scale based on that individual’s ability to pay. The care is delivered through a small number of government-registered provider entities (unlike the tens of thousands participating in Medicare and Medicaid), and each consumer who receives government-funded personal care also receives care management services to ensure the personal care they receive is coordinated with their other health and social service needs. In addition, the Australian program places significant responsibility on the beneficiary. If the consumer has a caregiver, their caregiver manages the services they receive, identifies and reports FWA by providing each consumer with regular, clear and transparent care planning, budgeting and billing.
This paper offers a few of the lessons learned in Australia that might prove valuable as the U.S. confronts the confluence of the ever-growing needs of an aging population and significant, validated concerns about FWA activity in Medicare and Medicaid.
Important Lessons from Australia
At the outset it should be noted that Australia’s Support at Home program is not a direct template for Medicaid. Unlike Medicare, which provides post-acute care but no long-term assistance with personal care needs, Medicaid provides personal care services available only to people with very low incomes and Older Americans Act services. Services under the Older Americans Act vary significantly both in availability and type by state. Australia’s Support at Home program is nationally funded and administered and available to all who need it on a sliding scale based on ability to pay. It operates under a completely different legal, market and coverage framework. However, several elements of how Australia’s program is designed and administered are relevant to the U.S. programs.
In Australia, funding is linked to a nationally standardized assessment and an individual support plan. Participants are assessed to qualify for one of eight ongoing funding classifications.6 This creates a clearer line between identified needs, authorized services and expenditures than a system driven primarily by individual claims without a common assessment architecture.
Government funding is allocated through registered providers in the Australian ecosystem. Providers are accountable for delivery, including for services arranged through third parties. This creates an identifiable control point for governance, workforce oversight, billing and remediation. It also reduces the risk that fragmented subcontracting obscures responsibility.
Claims and consumer information are used to reinforce each other. The Australian model requires services to be individually claimed and coded, while participants receive statements showing the services charged against their budget. Consumer-facing statements are more than an engagement tool. They can act as a distributed verification mechanism by enabling participants and families to identify services that were not received or do not match the care plan.
Care management is built into the funding model. Ten percent of an ongoing Support at Home participant’s budget is allocated to care management. This supports coordination across nursing, allied health, personal care, and everyday living services, while creating a professional role responsible for aligning delivery with assessed needs and goals.
Aspects of the Australian System that Mirror Challenges in the U.S.
While Australia’s system provides an example of how the U.S. might ensure a base level of support for seniors in need that is paired with stronger consumer responsibility and FWA controls, it is far from perfect. Like the U.S. system, the Australian system faces access and workforce pressures. As of March 31, 2026, 338,049 people were receiving ongoing Support at Home care from 950 Support at Home providers, and 100,191 were waiting in the priority system for an ongoing place at their approved classification or transitional level.7 Integrity controls therefore need to work alongside policies that expand legitimate capacity. Strong controls cannot substitute for adequate supply.
A Practical FWA Framework for U.S. Home Care Drawing on Lessons from Australia
Regardless of whether the U.S. continues to rely on Medicaid as the primary payer of home care services or looks to create a more universal approach, there are several critical lessons we can learn from the Australian experience:
- Implement a single accountable executive for program integrity, with clear escalation to a board or governing body, whether at the federal or state level. While the interagency fraud task forces have made enormous strides in addressing fraud in public programs, the work continues to be diffuse, program-specific and subject to capacity constraints.
- Consider limiting the participating provider universe to validated providers with a strong track record of operational integrity. As discussed, the entire provider universe in Australia is comprised of 950 Support at Home providers.8
- In Australia, all providers who receive government funding to deliver Support at Home go through a registration process to be eligible to deliver the program. This includes screening of the organization and key personnel within the organization. This is required to be kept up to date, and a re-registration process occurs every three years. The registered provider is also responsible for undertaking similar checks for any organization to which they subcontract services.
- Reconcile authorizations, schedules, visit evidence, payroll and claims data to identify impossible hours, overlapping shifts, travel anomalies and services billed during periods of ineligibility (for example, during periods of hospitalization). Give participants and authorized representatives clear, timely service statements and a simple process to dispute entries. Empower and incentivize consumers to report suspected fraud.
- Ensure adequate service capacity by helping providers to expand and improve their capabilities. Not all errors constitute FWA.9 Identify documentation defects, training gaps and system errors, provide necessary training, and track corrective actions and recurrence.
Recap and Recommendations
- For regulators, Australia’s most transferable lesson is accountable intermediation. A registered provider can coordinate care across multiple workers and services, but it should remain answerable for the quality, legitimacy and transparency of everything charged to public funds. U.S. policymakers could strengthen this principle through consistent provider screening, auditable subcontracting obligations, participant statements and common data standards across states.
- The policy objective should not be zero friction. It should be reliable evidence, clear accountability and earlier detection of risk. A proportionate framework can protect beneficiaries and public funds while preserving access to the home-based services that allow people to remain in their communities.
Footnotes:
1: House Committee on Energy & Commerce, Chairman Brett Guthrie, Press Release, “E&C Republicans Introduce Critical Fraud-Fighting Package to Protect Vulnerable Americans and Safeguard Taxpayer Dollars” (Sept. 29, 2026).
2: U.S. Department of Justice, Office of Public Affairs, Press Release, “Man Pleads Guilty in Connection with $17M Medicare Hospice Fraud and Home Health Care Fraud Schemes” (Feb. 3, 2025), .
3: U.S. Department of Justice, Office of Public Affairs. Press Release, “The Fraud Division Announces Charges Against 19 Defendants for Medicaid Home Health Aid Schemes” (Aug. 4, 2026).
4: ld.
5: United States Attorney’s Office, Eastern District of New York, Press Release, “Brooklyn Adult Daycare Owner Sentenced to 76 Months in Prison for Leadership Role in $68 Million Medicaid Fraud Scheme” (Sept. 9, 2026).
6: Australian Government, Department of Health, Disability and Ageing, “Funding classifications for Support at Home” (accessed Oct. 9, 2026).
7: Australian Government, Australian Institute of Health and Welfare, “Support at Home program data report 1 January – 31 March 2026” (May 31, 2026).
8: Id.
9: Centers for Medicare & Medicaid Services, “Fiscal Year 2025 Improper Payments Fact Sheet” (Jan. 15, 2026).
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2026年10月28日
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