Medicaid programs are in a period of heightened scrutiny, as states confront growing complexity in how these programs are administered and sustained. A recent Kaiser Family Foundation analysis highlights how states are grappling with rising program costs and tough tradeoffs, with total Medicaid spending projected to increase by 7.9% in FY 2026. In this environment, ensuring program integrity is no longer just about compliance, it’s central to sustaining access to care.
Nowhere is that imperative more apparent than in self-directed care programs, where rapid growth and increased visibility have raised the stakes for getting oversight right. Too often, the conversation around program integrity is framed in terms of enforcement: audits, investigations, and clawbacks after the fact. But that model is increasingly out of step with how modern, scalable programs actually operate.
To meet this moment, states must rethink how program integrity is designed and delivered by focusing on four key priorities that enable oversight to scale alongside these programs.
1. Program integrity is a team sport
The first priority is recognizing that program integrity cannot sit with a single team or function. In leading self-directed care programs, responsibility is shared across stakeholders, including state agencies, fiscal management services providers, service coordinators, health plans, participants, and caregivers.
When integrity is treated as a shared responsibility and reinforced through regular communication, problems surface faster and can be resolved at a lower cost. This collaborative model also helps translate program rules into daily operations, ensuring that compliance is actively practiced across the system.
As states look for ways to manage rising Medicaid costs and reduce the risk of fraud, waste, and abuse without reducing access to care, this kind of shared accountability is more important than ever.
2. EVV: Program integrity, not punishment
The second priority is reevaluating how core tools like Electronic Visit Verification (EVV) are used. EVV is often misunderstood as a mechanism for surveillance or enforcement. In practice, its greatest value lies in functioning as an early warning system.
For example, some programs now use EVV data to flag overlapping shifts or unusually high manual time entries, not to automatically deny payment, but to trigger outreach. In one case, tightening thresholds on manual entries led to improved compliance over time, supported by training and communication rather than punitive action. Similarly, data points like location mismatches are increasingly used to refine policies so they better reflect how care is actually delivered in the community.
When EVV data is used continuously, it can highlight patterns and prompt education, clarification, and course correction. This approach strengthens relationships within the program while ensuring safeguards remain effective. At a time when many states are still refining EVV requirements and responding to provider feedback, how these tools are used matters as much as whether they are implemented.
3. Eligibility: The core control that can prevent chaos
The third priority is strengthening eligibility verification as a proactive program integrity control. While it may not receive the same attention as other tools, eligibility plays a central role in preventing downstream issues.
Consider a common scenario: a participant’s eligibility status changes, but that update doesn’t reach all parts of the system. Services continue, payments are made, and the issue isn’t discovered until months later, triggering costly recoupment efforts and administrative burden for all involved.
States leading the charge in this area are building eligibility checks into multiple points across the service lifecycle: before enrollment, during authorization, and prior to payment. These frequent checkpoints ensure that services are authorized appropriately before payment occurs, reducing errors and avoiding the cost and operational strain associated with correcting them later.
4. When program integrity is boring, it’s working
The fourth priority is embedding continuous monitoring into everyday operations. The most effective program integrity models are often the least visible because they prevent problems before they require intervention.
In more mature models, controls are built directly into workflows. Eligibility is revalidated continuously, payments are released only when required conditions are met, and utilization is monitored in real time. The result is fewer “fire drills” and far less reliance on disruptive audits or post-payment recovery efforts. Improper payments become the exception — not the expectation.
Rather than relying on high-profile investigations, these models operate through ongoing checks and integrated controls. Over time, this creates a more stable system with fewer crises and less administrative burden.
Designing for scale and sustainability
These four priorities are especially important as self-directed care programs continue to grow in size and complexity. Larger programs require systems that can scale without introducing additional risk or administrative burden. A reactive integrity model that depends on post-payment enforcement cannot keep pace with that level of growth.
As states prepare for upcoming fiscal year changes and navigate increasing budget pressure, building systems that can scale without increasing risk is becoming a top priority. Designing integrity into operations from the outset allows programs to expand while maintaining control, transparency, and efficiency. It also positions states to better withstand scrutiny, prevent fraud, waste, and abuse, and ensure long-term sustainability.
In large-scale programs, these approaches are already surfacing patterns such as overlapping billing across multiple participants or time submitted during periods when services could not have been delivered. Identifying these issues early allows programs to correct behavior before it escalates into fraud investigations or service disruptions.
When implemented effectively, this approach does more than prevent fraud and reduce costs. It improves the experience for participants and caregivers, enables continuity, and builds trust in the system. In that environment, program integrity becomes a foundational element of high-quality care delivery rather than a barrier to it.
As Medicaid programs continue to evolve, the question is no longer whether to modernize program integrity. The real question is how quickly systems can adopt these principles to prevent problems before they occur — while supporting the people who rely on these programs every day.
Photo: designer491, Getty Images
Tara Himmel, PPL’s Chief Marketing Officer, leads marketing, communications and government relations for the organization. Tara has dedicated over 20 years to advancing PPL’s mission and has been central to the company’s evolution and long-term success as the market leader in self-directed care.
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