A New Tool to Fight Fraud From Inside

Value-based care promotes Medicaid transparency in an enhanced era of compliance

By Stephen Vaccaro

Medicaid and those who rely on it continue to evolve through one of the most significant periods of transformation in the program’s history. Providers across the home- and community-based services (HCBS) industry are adapting to updated regulations with heightened transparency, compliance and accountability requirements. Although change can bring uncertainty, it also creates opportunities to improve how care is delivered and strengthen program integrity.

Adjusting to new laws can be intimidating, but it’s important to dedicate time and attention to fully understanding the ways in which provisions can be leveraged for positive outcomes. The recently passed One Big Beautiful Bill Act, for example, expands HCBS waiver authority—potentially reducing waitlists and increasing access to care—and outlines rural health care initiatives to help providers reach underserved communities. Just as importantly, the bill puts a spotlight on fraud, waste and abuse, underscoring the importance of technologies like electronic visit verification (EVV) in safeguarding Medicaid programs and ensuring resources are used wisely.

Value-Based Care Encourages Continued Progress

Providers seeking ways to enhance their alignment with the new guidelines and protect their operations needn’t look far. For many, the answer is already a part of their daily workflows. Value-based care (VBC), a model commonly used by agencies to improve outcomes and lower costs, ties reimbursement to measurable, data-backed results rather than service volume. Beyond its clinical and financial benefits, VBC introduces a system of accountability that helps to protect Medicaid’s integrity.

Because this model requires accurate documentation and reporting, it becomes common practice for providers to collect and log data during client visits. Entering that information into EVV platforms in real time streamlines billing and reimbursement—with some agencies reporting savings of up to 66% in administrative costs—and serves as proof of regulatory adherence. The same data that ensures providers get paid for care that meets high standards also demonstrates that services were delivered as reported, leaving little room for error or abuse. The process also enhances the client and family experience by verifying care is administered consistently and transparently.

This routine becomes even easier when providers leverage integrated tools to support their VBC and compliance efforts. Unified, interoperable solutions with mobile features are often designed to integrate seamlessly with external systems, such as electronic health records (EHRs) and other hospital network components. The connections facilitate instant data availability, decreasing the administrative work traditionally associated with maintaining compliance and helping caregivers make faster, more informed decisions that boost the likelihood of positive outcomes.

In fact, hospitals using VBC models as part of a Centers for Medicare & Medicaid Services (CMS) program to reduce readmissions saw readmissions drop over the course of several years by 3%-5%.

Recent & Expected Growth of VBC Underscores Need for Providers to Keep Pace

The push toward VBC in Medicaid-funded homecare picked up speed when the value-based payment (VBP) component of the Medicaid Innovation Accelerator Program (IAP) was launched in 2014. The program, which equips states and providers with the tools and technical support needed to design and implement VBP models, helps organizations understand the impact of different payment strategies before launching them.

For agencies looking to implement value-based care or better align their programs with evolving requirements, VBP models offer a straightforward way to improve quality, reduce costs and ensure accountability. Other actionable strategies providers can take to support their efforts include:

Investing in technology to streamline documentation and reporting
Building compliance into everyday workflows, not just audits
Leveraging data to identify anomalies early and prevent fraud
Training staff to align care delivery with outcome-based measures

By 2030, CMS aims to move nearly all Medicaid spending into accountable care models, where providers are responsible not just for delivering care, but also for the quality and total cost of that care. This shift, part of the CMS Innovation Center’s strategic refresh, underscores policymakers’ ongoing quest to make VBC the standard.

In stricter regulatory environments, providers that pursue VBC to protect resources and clients gain a clear competitive edge over those who wait. The approach has the added benefit of strengthening cost-control measures and supporting long-term Medicaid integrity. While the transition takes time, steady progress and incremental gains will consistently build momentum toward greater VBC adoption and comprehensive compliance. When compliance is achieved, clients reap the benefits of improved health, stability and more sustainable support systems.

Stephen Vaccaro serves as president at HHAeXchange, the leading provider of homecare management solutions for providers, managed care organizations and state Medicaid agencies, where he leads the market strategy and national expansion of HHAeXchange’s state, payer, provider and self direction purpose-built technology solutions. With more than 30 years of leadership experience in the healthcare technology space, Vaccaro understands the business needs of all stakeholders in the homecare ecosystem. He has a proven track record of success in executive leadership, sales, implementation, service delivery, strategic planning, project management, product development and acquisition integration. Visit hhaexchange.com.