Recommendations to Address Fraud, Waste, and Abuse in Medicaid HCBS

In June, the MLTSS Association sent a letter to CMS outlining recommendations to support program integrity in Medicaid Home and Community-Based Services (HCBS).

MLTSS plans invest substantially in fraud, waste, and abuse (FWA) detection and prevention through both upstream controls and layered detection models, including credentialing and provider enrollment validation, person-centered planning processes, and authorization guardrails, which work to prevent FWA before it occurs. These efforts are further reinforced by layered FWA detection models that incorporate real-time monitoring, pre-payment review, and post-payment analytics, including Electronic Visit Verification (EVV). However, structural barriers, including inconsistent state policies, limited data sharing authority, and gaps in federal guidance and regulation, constrain what plans can accomplish independently.

Our recommendations reflect the collective experience of MLTSS Association member plans and are intended to strengthen the federal-state-plan partnership in addressing FWA across all delivery settings while preserving access to critical services for our members. Altogether, these recommendations underscore areas of concern for plans related to FWA, barriers health plans face enforcing protections against FWA, the need to highlight state best practices, and areas for improvement at the plan, state and federal level.

Read our full recommendations here