M&Y Care, LLC

West Bloomfield, MI 2015--2023 Home Health / Home Care

DOJ HHS-OIG Michigan Attorney General Health Care Fraud Division Medicare Medicaid Fraud False Claims Act Unlicensed Staff Upcoding

Penalty

$334,807

Outcome

M&Y Care, LLC paid $334,807 to resolve False Claims Act allegations that it billed Medicare and Medicaid using the home health aide CPT code G0156 for services provided by individuals who were insufficiently trained to qualify for that billing code, when the services should have been billed at the lower non-skilled care rate.

Details

M&Y Care, LLC — Home Health Aide Code Billing for Unqualified Staff (2025)

Outcome: M&Y Care, LLC, a home health agency in West Bloomfield, Michigan, paid $334,807 to resolve False Claims Act allegations that it billed Medicare and Medicaid for home health aide services using CPT code G0156 when the individuals delivering those services did not have the training required to qualify for that billing code, and the services should have been billed at the applicable non-skilled care rate.

M&Y Care, LLC provides home health care services to patients in Michigan, including personal care services, with its principal place of business in West Bloomfield, Michigan.

The settlement resolves allegations covering the period January 1, 2015 through December 31, 2023 — an eight-year span. The United States contended that M&Y Care billed Medicare and Medicaid using CPT code G0156, which pertains to services provided by a home health aide under a home health plan of care. Proper use of this code requires that the delivering staff member meet the home health aide training and competency standards established under Medicare conditions of participation at 42 CFR Part 484. M&Y Care instead used G0156 for services delivered by staff members who were insufficiently trained to meet that standard, when the applicable billing code would have been a lower-reimbursing non-skilled care code.

The result was a systematic upcoding pattern — billing at the skilled home health aide rate for services rendered by workers who qualified only for lower-acuity non-skilled care reimbursement. The violation is a compliance risk common in home health agencies operating in competitive labor markets where staff training records are not integrated with billing systems.

The case was resolved through a coordinated effort by the U.S. Attorney's Office for the Eastern District of Michigan, HHS-OIG, and the Michigan Attorney General's Health Care Fraud Division. The settlement was announced in 2025.

Primary Source: Home Health Care Provider To Pay $334,807 To Settle False Claims Act Allegations — DOJ Eastern District of Michigan

How Crucible Prevents This

Crucible staff credentialing controls with a pre-billing verification gate would prevent the use of CPT code G0156 unless the delivering staff member's training records confirm they meet the home health aide qualification standard under 42 CFR. An automated billing code eligibility check comparing the assigned billing code against the delivering staff member's credential record would catch this category of upcoding at the claim level before submission. A periodic audit module comparing billed CPT codes to staff training records would surface systematic misuse across an entire workforce.

Source: Home Health Care Provider To Pay $334,807 To Settle False Claims Act Allegations — DOJ Eastern District of Michigan

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