FWA Insights: Identifying adult day health billing schemes

Adult day health (ADH) programs are intended to support vulnerable populations, including older adults and adults who require supervision during the day. But improper billing practices, noncompliance with state age requirements, and potential patient recruitment schemes highlight the need for increased payer vigilance against fraud, waste, and abuse (FWA). In fact, throughout 2025 and into 2026, Cotiviti’s own investigators observed a rise in questionable billing patterns among ADH providers, particularly involving basic and enhanced service levels.

In this edition of FWA Insights, we examine how Cotiviti’s investigators identified outlier providers, what their analysis uncovered, and how health plans can strengthen oversight of ADH billing.