OIG Issues Unfavorable Advisory Opinion on Sign-On Bonuses for Home Care Attendants

On January 5, 2026, the Office of Inspector General (OIG) posted Advisory Opinion No. 25-12, concluding that a proposed arrangement by a home care agency to offer sign-on bonuses to prospective employees would present significant fraud and abuse risks under the Federal anti-kickback statute and the Beneficiary Inducements civil monetary penalty (CMP) law.

Background

The requestors operate a home care agency in a state Medicaid program that covers in-home support services through waiver programs. Under these programs, clients may select attendants, often family members, to provide personal care, homemaker services, and certain health maintenance activities. Agencies employ attendants, submit claims to Medicaid, and must meet staffing and supervision requirements.

To remain competitive, the requestors proposed marketing sign-on bonuses to prospective attendants. The agency expected that most attendants would be family members of clients and would act as decision-makers in selecting the agency to provide Medicaid-reimbursable services to those clients.

OIG’s Analysis

OIG determined that the proposed arrangement would implicate both the Federal anti-kickback statute and the Beneficiary Inducements CMP because:

• The sign-on bonus would likely influence attendants, who often select the agency on behalf of their family members, to choose the requestors’ agency for Medicaid-covered services.
• The arrangement does not qualify for the statutory employee exception or safe harbor because the bonus offer and advertising effectively operate as a solicitation for referrals before employment begins.
• The structure creates an “inextricable link” between employment and referral, presenting heightened risk compared to typical sign-on bonuses.

OIG emphasized that the advertisements, which would state only the bonus amount, could be perceived as upfront payments thus steering attendants to select agencies based on financial incentives rather than quality of care. This dynamic could lead to unfair competition, escalating bonus offers, and diversion of resources from patient care.

OIG issued an unfavorable opinion, concluding that the proposed arrangement would constitute a prohibited offer of remuneration under both the anti-kickback statute and the Beneficiary Inducements CMP, subjecting the parties to potential sanctions if implemented with the requisite intent. 

Providers and agencies should structure any bonuses for recruitment purposes so they are not tied, directly or indirectly, to the choice of agency for a family member’s care to ensure that recruitment efforts target a broad pool of candidates, not just those likely to influence client referrals.

As is always the case for OIG advisory opinions, this advisory opinion is based on the specific facts provided by the requestors and is binding only on the requestors.  However, OIG’s analysis and opinion may serve as helpful guidance to those providers who seek to find creative solutions to helping patients and families receive necessary care.

Reed Smith will continue to follow developments related to health care fraud and abuse enforcement. For more information on this advisory opinion or the impact of OIG’s guidance on your business, or for advice on seeking an advisory opinion, please contact the author or a member of the Reed Smith health care team.