Assurance
Pennsylvania Medicaid · Home Care Fraud Prevention
A pre-payment prevention and post-payment forensic audit system for home care billing, purpose-built for the Special Investigation Units of Pennsylvania Medicaid MCOs.
The Problem
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, client kickbacks, is a future consideration.
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).
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.
The Platform
Built and tested on a fully synthetic 365-day dataset simulating a 9-agency provider network (123 caregivers, 88 clients, 23,798 shifts). Most of the planted fraud sits in one agency, so the agency rollup has a clear outlier to find. All 30 planted cases were caught, and none of the 77 clean caregivers were flagged.
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 patterns these modules flag appear in federal DOJ enforcement actions and in CMS's national Medicaid personal-care vulnerability research, and the 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.
Request a walkthroughAgency-Level Oversight
Every module above flags something at the level of one caregiver or one claim. Assurance also rolls those same flags up to the agency level, showing when flagged activity concentrates at a single provider instead of spreading evenly across a network. Each rollup lists the flags behind it, so an SIU can see what drives the concentration.
The goal is to protect the agencies that bill correctly. They compete with, and share the reputational cost of, the few whose billing puts funding at risk for everyone.
In our own 365-day, 9-agency simulated network, the rollup showed one agency at 3.0x the network's average flag concentration, while the quietest agencies sat at 0.23x or lower.
Assurance flags, and the SIU decides. Every agency-level flag comes with the underlying incidents attached. Assurance gives the SIU a documented reason to open an investigation, and the investigation, due process and judgment belong to the SIU.
Request a walkthroughData Handling & Compliance
Because we're pre-launch, our discovery and pilot phases run on a strict zero-PHI architecture — we don't accept or process live patient data. Pilots run on fully de-identified, historical extracts, so there's no HIPAA exposure to your organization at this stage.
We're designing our production environment for deployment onto HIPAA-compliant, BAA-backed cloud infrastructure, and will map our internal controls to SOC 2 Type I requirements as we move toward a signed pilot.
Specific data handling terms — retention, deletion, and processing commitments — are detailed in our Data Specification & Handling Sheet, available on request.
Let's Talk
If you're with a Pennsylvania Medicaid MCO's Special Investigations Unit, I'd like to set up a live demo — a walkthrough of how Assurance flags questionable claims before they're paid, with the option to run it against your own claims data.
Fill out our contact form → or email hello@visitintegrity.com directlyAssurance is currently in early conversations with Pennsylvania Medicaid MCOs and is not yet in production with any payer.
