State and federal regulators are placing Medicaid programs under heightened oversight, particularly as
Medicaid represents roughly 30% of state budgets. On September 22nd, Therap Services hosted a virtual
event titled "Program Integrity for States and Providers: How to Identify and Avoid Fraud, Waste, and
Abuse" to share trends in regulatory enforcement and how best practices in documentation can support
program integrity. This article summarizes the key takeaways and insights shared during the event.
Federal oversight agencies, including the Centers for Medicare & Medicaid
Services (CMS) and the Department of Health and Human Services (HHS), are deploying sophisticated
monitoring tools to examine state program management and mitigate financial risks. Key federal
developments highlighted during the event include: Utilizing a dedicated Data Fusion Center to analyze real-time billing data, allowing federal
prosecutors to open investigations within days. Established in March 2026 to coordinate cross-agency anti-fraud strategies, resulting in
significant funding deferrals for states with insufficient oversight frameworks. Seeking input to draft Comprehensive Regulations to Uncover Suspicious Healthcare to
strengthen provider verification standards. CMS implemented temporary nationwide enrollment pauses for DMEPOS suppliers in February 2026,
followed by pauses for Home Health Agencies and Hospices in May 2026 to target high-risk
billing areas. States are taking varied paths, combining proactive and reactive measures to
manage funding and maintain compliance standards. Here are some examples that reflect different
approaches across the country: Reinstated mandatory GPS tracking for Electronic Visit Verification (EVV), expanded EVV
requirements to include live-in caregivers, paused new home health enrollments, and
increased criminal penalties for fraud. Initiated targeted enforcement across day programs, froze admissions across 13 high-risk
Medicaid service categories, mandated unannounced site visits, and deployed artificial
intelligence to block suspicious claims prior to payment disbursement. Addressed a $1.3 billion federal payment deferral by presenting detailed audit documentation
while mobilizing state fraud units to prosecute bad actors. Established a dedicated strike force following federal decertification of its Medicaid Fraud
Control Unit due to a multi-year lack of convictions. Speakers also addressed upcoming policy requirements, such as the January 1, 2027
Medicaid employment mandate requiring non-exempt adults to document 80 hours per month of work,
education, or community engagement. Navigating heightened regulatory scrutiny without creating excessive
administrative strain requires electronic documentation built around proactive risk management, clear
governance, and verifiable records. Establishing documentation best practices is critical for providers
to demonstrate program integrity across daily operations. A primary source of audit risk stems from disconnected billing workflows or manual claim
creation. Providers can mitigate this risk by directly linking claim generation to
time-stamped and date-stamped service documentation. When claims are backed by point-of-care
logs, it reduces unsubstantiated billing submissions and manual data entry errors. For agencies delivering community-based care, strong EVV capabilities are essential. Systems
should capture location coordinates, start and end times, and caregiver verification at the
moment service occurs at the point of service. When manual edits or exceptions occur,
capturing required reason codes and maintaining an immutable audit trail provides full
visibility into administrative changes. Maintaining strict control over data modifications protects agencies during post-payment
reviews. Implementing granular, role-based permission settings restricts data edits strictly
to authorized personnel. Logging all user actions, note modifications, and permission
updates promotes complete transparency, helping quality assurance teams spot unusual edit
patterns early. Distinguishing legitimate care delivery from allegations of service waste requires clear
evidence of goal tracking. Support teams should align daily notes directly with Individual
Support Plan (ISP) goals and measurable objectives. Integrated dashboards and reporting
tools allow leadership to monitor service utilization, identify documentation gaps, and
confirm that authorized services support individual outcomes. Instead of waiting for external audits, agencies should build strong internal Quality
Assurance processes. Reporting dashboards, especially those powered by Artificial
Intelligence, can be vital for these self-audits as a way of identifying trends and
outliers. Real-time reporting highlights missing notes, unapproved units, or unexpected
spikes in service delivery, giving management actionable information to correct errors prior
to claim submission.
Preparing for heightened state and federal scrutiny requires a documentation system built for
accountability,
clarity, and operational efficiency. Therap's tools are designed to do just that. Therap enables
organizations
to link billing seamlessly with verifiable records, including EVV and other point-of-care documentation,
minimizing the risk of unsubstantiated claims. Therap also offers integrated reporting dashboards and
Artificial Intelligence features like AI Analyses that empower provider leadership to conduct continuous
self-audits, monitor service utilization, enforce role-based governance, and ultimately demonstrate
program
integrity while focusing on person-centered care.
Program Integrity in Human Services:
Key Takeaways on Identifying and Avoiding for Fraud, Waste, and
Abuse
Defining Fraud, Waste, and Abuse
Term
Definition
Key Compliance & Operational Risks
Fraud
Intentional deception to obtain an
unauthorized financial benefit.
Falsified
timesheets and other documentation; billing for unrendered services.
Waste
Misuse or overuse of resources causing
unnecessary spending, or underutilization leading to poor outcomes.
Service overuse,
rolling over service packages without connecting them to the person's plan and goals, or
unmonitored care leading to avoidable ER visits.
Abuse
Practices resulting in unnecessary costs when
payment is made without legal entitlement (lacks fraudulent intent).
Unverified
patient eligibility, expired staff certifications/licenses, or billing without proper
authorization.
The Heightened Regulatory Landscape
DOJ National Fraud Enforcement Division
White House Task Force
CMS CRUSH Initiative
Enrollment Moratoriums
State-Level Approaches to Oversight
Ohio
Minnesota
California
Hawaii
Key Documentation Best Practices for Program Integrity
Billing Directly Linked to Documentation
Robust Electronic Visit Verification (EVV) and Audit Trails
Role-Based Permissions and Governance Controls
Outcome-Focused, Person-Centered Documentation
Proactive Quality Assurance and Reporting
How Therap Can Help
Sources
Therap Blogs
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