The Answer to Fraud Is Not Less Care for People Who Truly Need Care

Warning…long post 😉

The Answer to Fraud Is Not Less Care for People Who Truly Need Care

I have been digging, researching, asking questions, and trying to understand Ohio’s home-care system for close to a year now….well, longer than a year, but more intensely for about a year. 

The more I learn, the more I see a pattern.

Many of the weakest areas in the system are the very areas some people may be exploiting.

Fraud matters, oversight matters, Medicaid dollars matter, and vulnerable people matter, 

Recently, I listened to the original video from Daily Wire investigative reporter Luke Rosiak regarding alleged Medicaid fraud connected to home care in Ohio. I still need to read the full report, but even from what I have heard and already been researching, it seems clear that there are serious concerns. Here’s a link to the video https://youtu.be/blXtvTptWcQ?is=vYGDEhTeDn4cNQMO

LLCs are being created, there are MAJOR billing concerns, and questionable home-care operations.

People hiding behind the language of healthcare or home care while possibly exploiting a system meant to support vulnerable people.

That should absolutely be investigated, addressed, and most certainly not ignored. However, here is where we have to be very careful. The  problem is not that home care exists.

The problem is that oversight appears weak in the wrong places, while medically complex families may be scrutinized, destabilized, or punished in ways that do not solve the fraud problem.

I have not been asking these questions casually.

For months, I have been calling, emailing, reading rules, asking agencies, asking state-level contacts, reaching out to legislators, communicating with the Governor’s office, and trying to understand where the weak points are.

Who oversees home-care agencies?

How does someone start one?

Who verifies competency?

Who confirms billed services were actually provided?

Who determines whether a provider is truly appropriate for a medically complex individual?

Who recognizes when broad categories like “home care,” “nursing,” “ventilator,” or “provider” are not specific enough?

Too often, the answers have felt more like process explanations than true engagement with the root concern.

I am told there is a physician order, a nursing assessment, a care plan, an ISP, a provider approval process, a billing process, a review process, A rule, a form, a pathway, etc..

Those things may exist. But the existence of a process does not prove that the process is asking the right questions.

And it does not prove that the people reviewing, approving, assessing, or overseeing the care understand what can be missed, mismatched, or misinterpreted in a medically complex situation.

For someone like my son Alex, even basic home-care oversight can become complicated if the person doing the oversight does not understand the medical reality.

A temperature can be charted, but misunderstood.

Respirations can be counted, but not interpreted in context. Alex uses two forms of life support, both of which are set to regulate the number of respirations. The pacer is the main support. It could literally be creating the 16 breaths it is set at, which means the count would be 16 respirations, and yet, Alex could be in major trouble. 

A pulse ox number can look fine while Alex is already telling someone his airway needs cleared.

A diagnosis label can be present but medically incomplete. (That’s a BIG one with Alex that we’re trying to address) 

A provider can be licensed but not case-specifically competent.

A facility can say it accepts ventilators while not understanding diaphragm pacing, autonomic instability, airway timing, equipment interaction, communication, or rapid physiologic change….i know that because i talked to them myself. 

That is where weak oversight becomes dangerous.

Oversight done by people who do not understand what they are looking at can create a false sense of safety.

It can miss fraud.

It can miss neglect.

It can miss incompetence.

It can miss medical risk.

And it can misclassify legitimate, life-sustaining care as excessive while failing to identify care that is fraudulent, unsafe, or not actually being delivered.

There is a real danger here.

When fraud is uncovered, systems often look for quick ways to show they are “doing something.”

But doing something is not the same as doing the right thing.

If the response to fraud is to broadly weaken home-based supports, restrict family caregivers, reduce flexibility, or push medically complex individuals toward facilities, the system may harm the very people legitimate care is keeping alive, stable, and out of institutions.

Fraud prevention should target fraud.

It should not dismantle the supports that keep medically complex people alive, stable, and living in the community.

If the system responds to fraud by weakening legitimate home-based supports, it may create more institutionalization, more crisis care, and more cost — while still failing to address the root oversight problem.

That is not reform That is missing the point! 

The answer to fraud is not less care for people who truly need care. The  answer is better oversight of those abusing care.

There are really two problems happening at the same time. One problem is fraud and the other problem is the failure to understand medical complexity.

Those are not the same problem.

Fraud involves people billing improperly, exploiting programs, misrepresenting services, or using vulnerable people and public dollars for personal gain.

Medical complexity involves individuals whose bodies require highly individualized, competent, consistent support to remain safe in the community.

If policymakers confuse those two things, the solution can become dangerous.

They may clamp down on the people easiest to regulate instead of the people actually exploiting the system.

They may remove supports from stable medically complex people instead of building the oversight needed to distinguish legitimate care from fraudulent billing.

That’s is the baby with the bath water.

And in medically complex situations, that “baby” may be a real person whose stability depends on the supports being threatened.

For Alex, home care is not a convenience, an extra, a loophole, or a luxury. We sure do wish we did not “need” to rely on support, but we do. 

It is part of the structure that has allowed him to live at home for more than 21 years after catastrophic injuries.

Alex is medically complex. He uses advanced respiratory support. His body does not always respond in textbook ways. His stability depends on individualized care, prevention, consistency, communication, equipment knowledge, and people who understand his warning signs.

If those supports were weakened or removed in the name of fraud prevention, the result would not be accountability.

The result could be medical destabilization.

And if that destabilization then led someone to say, “See, he needs a facility,” the system would have created the crisis it later used to justify institutional care.

That is not informed choice, or person-centered planning, or protection. That is a system failing to distinguish between abuse of care and the need for care.

My friend and I have a little saying we talk about:

The thing that we think is the thing is never the thing; it’s everything God is doing around that thing to draw us to Him. I keep thinking about that here.

At first glance, the thing may appear to be Medicaid fraud. And  yes, fraud is real and should be addressed.But maybe there is also something deeper being exposed…weak  oversight…Misaligned incentives…and  lack  of meaningful accountability.

A system that may not know the difference between a shell operation and a medically necessary support structure.

A system that may question legitimate family care while missing larger patterns of abuse.

A system that may understand billing codes better than bodies.

A system that may know how to authorize hours but not how to evaluate case-specific competency.

A system that may react to fraud by cutting support instead of asking better questions.

Maybe the deeper issue is not simply fraud. Maybe the deeper issue is whether our systems are wise enough, honest enough, and humble enough to protect the vulnerable while addressing the abuse.

That is where I keep asking God for wisdom.Because the goal should be to help, not hurt. To protect, not destabilize. To expose wrongdoing, not punish legitimate need. To strengthen oversight, not weaken care.

And to stop fraud, not stop life-giving support! 

The vulnerable should not pay the price for the actions of those exploiting the system.

Medically complex individuals should not be pushed toward facilities because the system failed to build smart oversight.

Families providing legitimate care should not be treated as suspicious simply because fraud exists elsewhere.

And home care should not be blamed as the problem when the real issue may be weak oversight, poor accountability, and failure to distinguish between very different realities.

The answer to fraud is not less care for people who truly need care.

The answer is better oversight of those abusing care.

Better questions, better safeguards, better accountability, and better understanding of the medically complex. 

Better protection for people whose lives depend on legitimate home-based support.

Fraud must be addressed, but reform that harms the vulnerable is not reform. It is another failure.

And we should be very careful not to create a bigger crisis while claiming to solve one.