Hospice and home-health investigations can involve patient eligibility, certifications, claims, referral relationships, ownership, enrollment, payment suspensions, and the work of providers, billers, marketers, and outside companies. A matter may begin with a CMS or payer review, DHCS audit, records request, interview, subpoena, or search warrant before any criminal charge.
An unfavorable audit finding or clinical disagreement is not automatically fraud. The government must prove the elements and required mental state of the selected law. Our California healthcare fraud guide covers the wider framework; this page focuses on hospice and home-health program allegations.
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CMS explains that Medicare hospice generally requires care through a Medicare-certified hospice, certification of terminal illness with a prognosis of six months or less if the illness runs its normal course, and a patient election of the benefit. A later live discharge, change in prognosis, or dispute over clinical judgment does not by itself prove that an earlier certification was knowingly false.
CMS home-health guidance describes eligibility requirements including homebound status, care under a physician or allowed practitioner, a plan of care, and a qualifying need for skilled services. Documentation, face-to-face encounter, certification, and medical-necessity issues can affect payment. A missing note, denial, or retrospective disagreement is not automatically a criminal scheme.
Do not alter, backdate, recreate, selectively delete, or “clean up” records. Routine deletion may need to be suspended. Counsel can define custodians, preserve original clinical and billing history, and separate patient-care continuity from the investigative response.
Investigators may allege that a patient did not exist, did not elect the benefit, was deceased, never received the billed service, or had identifying information used without authorization. Patient identity, consent, intake, visit, signature, device, location, and claim data should be traced rather than assuming every mismatch is deliberate theft.
Hospice cases may challenge terminal-illness certifications or supporting narratives. Home-health cases may challenge homebound status, skilled need, face-to-face documentation, or a plan of care. The defense may involve contemporaneous findings, disease trajectory, practitioner judgment, record sources, later events, and who prepared or relied on each certification.
Claims may be flagged for visits not performed, inflated service levels, unsupported continuous or inpatient care, duplicate billing, incorrect dates, or false provider information. Scheduling, visit-verification, clinical records, claim history, and system workflows matter. See our medical billing fraud defense page for claim-mechanics issues.
Investigators may scrutinize compensation to marketers, recruiters, facilities, physicians, owners, patients, or referral sources. The actual agreement, services, fair-market evidence, payment purpose, program, exceptions, safe harbors, and connection to claims determine the legal analysis. Not every marketing, employment, or referral arrangement is an unlawful kickback.
California Penal Code section 550 includes distinct health-care-benefit claim offenses. Sections 550(a)(6) through (9) address knowingly false claims, benefits not used by or for the claimant, duplicate claims with intent to defraud, and specified undercharge/overcharge conduct; section 550(a)(10) addresses qualifying workers’ compensation health-benefit claims. The section 550(c)(2) amount and aggregation rules affect charging and punishment, not whether fraud occurred.
Welfare and Institutions Code section 14107 addresses specified false Medi-Cal claims, false information, and schemes involving Medi-Cal or other DHCS-administered programs. Section 14107.2 addresses specified remuneration connected to referrals or ordering of covered services, subject to statutory exceptions. These laws may matter when Medi-Cal paid or authorized the care.
18 U.S.C. section 1347 addresses knowingly and willfully executing or attempting a healthcare-fraud scheme. Section 1035 addresses specified materially false statements and documents in healthcare matters. 42 U.S.C. section 1320a-7b includes federal healthcare-program false-statement and Anti-Kickback Statute provisions, with exceptions and safe harbors requiring fact-specific review.
Medicare allegations may require a federal defense strategy. Program-specific jurisdiction and agency roles are explained in our Medicare and Medi-Cal fraud defense guide.
On May 13, 2026, CMS announced a six-month nationwide moratorium on new Medicare enrollments and certain changes in majority ownership for hospices and home-health agencies. CMS also identified California as an elevated-risk state for hospice oversight. The moratorium is an enrollment policy; it does not prove that any particular existing provider committed fraud.
CMS’s Q1 2026 program-integrity materials reported more than 200 Medicare payment suspensions involving high-risk hospice and home-health providers in California. A suspension is an administrative action, not a criminal conviction, and the notice, basis, good-cause issues, data, and available process should be reviewed.
Official DOJ releases also show current theories authorities are pursuing. A June 2026 Southern California takedown release described hospice charges alleging medically unnecessary services, deceased beneficiaries, kickbacks, and identity information; charges are allegations and defendants are presumed innocent unless proven guilty. A July 2026 Northern California release reported a jury conviction involving a home-health agency and allegations proved at trial concerning services, records, and concealment. These examples do not predict another case or establish guilt by similarity.
DHCS says its Investigations Division uses complaints, referrals, and data analytics, and describes temporary payment suspension and referral procedures after a credible allegation of fraud, subject to good-cause exceptions. California DOJ DMFEA is the state Medicaid Fraud Control Unit. Federal matters may involve CMS contractors, HHS-OIG, FBI, DOJ, or other agencies.
A subpoena, interview, or warrant creates different duties and risks. Preserve the document and records, identify whether a request is voluntary or compulsory, and avoid guessing or obstructing. Our healthcare fraud investigation and subpoena guide explains early-response issues. There is no universal fixed investigation timeline.
Ownership, employment, access credentials, or receipt of revenue does not automatically prove knowing participation. Investigators may examine instructions, authority, compensation, patient sourcing, claim access, edits, warnings, training, supervision, corrections, and concealment. The defense should map each person to each disputed patient, certification, visit, claim, referral, and record.
An outside biller or marketer does not automatically transfer all responsibility away from a provider, and the provider’s obligations do not automatically make every contractor criminally liable. Contracts, role boundaries, access controls, disclosures, genuine services, and actual knowledge matter. Reliance on qualified staff or advice may be relevant when facts were fully disclosed and the reliance was genuine.
The federal False Claims Act is a separate civil statute with its own knowledge, materiality, procedures, and remedies. HHS-OIG separately identifies criminal and civil actions, civil monetary penalties, exclusions, state actions, and self-disclosures. Enrollment denial, revocation, recoupment, payment suspension, survey findings, accreditation, and licensing actions are not criminal convictions.
Licensed clinicians and administrators may need coordinated professional criminal and licensing defense. Private-payer claims may overlap with insurance fraud defense, while ownership and financial-record allegations may implicate white-collar defense.
No defense applies automatically. Correction, repayment, disclosure, or cooperation can affect several proceedings and should be evaluated before action. No dismissal, payment, enrollment, exclusion, licensing, or sentencing outcome can be promised.
No. A patient can improve, revoke an election, transfer, or be discharged for legitimate reasons. Investigators may examine patterns and records, but an individual discharge does not establish a knowingly false certification.
No. Homebound status can be fact-sensitive. Criminal liability requires the elements and mental state of the charged law, not merely a denied claim or retrospective disagreement.
Ownership alone is insufficient. Authority, instructions, compensation, knowledge, warnings, corrections, and connection to claims or referrals are relevant.
No. It is an administrative action. The notice, authority, data, good-cause issues, deadlines, and parallel referral should be reviewed promptly.
No. The program, payment, purpose, actual services, fair-market evidence, exceptions, safe harbors, and required intent must be analyzed.
They can trigger scrutiny, but mismatched information may also reflect clerical, enrollment, or system errors. Records must connect the accused person to knowing misuse.
Preserve the request and records, identify whether it is compulsory or voluntary, do not alter evidence or guess, and obtain advice about scope, privilege, status, and coordinated response.
This page provides general information, not legal advice. Reading it, calling the firm, or submitting information does not by itself create an attorney-client relationship. Laws and procedures can change, and every matter depends on its facts, evidence, jurisdiction, and timing. Past results do not guarantee a future outcome.
Call 888-702-8882 to discuss a hospice or home-health fraud investigation with My Rights Law.
This page was written by the My Rights Law Editorial Team and reviewed for legal accuracy by Bobby Shamuilian.
Attorney Shamuilian is the founder and managing partner of My Rights Law and is widely recognized as a legal authority, frequently appearing as a legal analyst and TV pundit on national news outlets.
He has earned a perfect “10.0 – Top Attorney” rating on AVVO and a “10.0” rating on Justia, and has been named among the “Top 40 Under 40” and the “Top 100 Trial Lawyers” by The National Trial Lawyers.
With his proven expertise and dedication, Mr. Shamuilian is committed to protecting your rights and achieving the best possible outcome for your case.
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