There is no shortage of news, federal activity, and operational urgency concerning fraud, waste, and abuse (FWA) in healthcare. Across Medicare, Medicaid, the Affordable Care Act Marketplaces, and other federally funded health programs, the executive branch is advancing a more aggressive program integrity agenda. The US Department of Health and Human Services (HHS), including the Centers for Medicare & Medicaid Services (CMS) and HHS Office of Inspector General, as well as the US Department of Justice, are placing greater emphasis on payment accuracy, provider and vendor oversight, data-driven detection, and defensible compliance processes.
As scrutiny intensifies, organizations across the healthcare ecosystem are challenged to move beyond traditional audit and recovery activities toward a more proactive, enterprise-wide approach to managing risk and preventing FWA. Although these trends affect all healthcare stakeholders, the implications for Medicaid are particularly significant given the program’s scale, complexity, and reliance on partnerships among state agencies, managed care organizations, providers, and technology vendors.
To better understand how organizations should respond, Jennifer Colamonico connected with Clint Eisenhower, Regional Director at Health Management Associates (HMA), and Jennifer Bridgeforth, Associate Principal at HMA. The discussion below incorporates insights from HMA colleagues Christine Rein, Amber Swartzell, and Elizabeth Linville, who joined HMA’s August 12, 2026, webinar on how new program integrity expectations are affecting Medicaid payment, operations, and compliance strategies.
Jennifer Colamonico: We hear a lot lately about heightened scrutiny and program integrity. What’s fundamentally different about this moment from what Medicaid leaders and their organizations have experienced in the past?
Clint Eisenhower: The biggest shift is that program integrity can no longer be viewed as a narrow compliance function. What we are seeing now is a move toward enterprise accountability—and we are really at the outset of this journey. Program integrity touches finance, operations, eligibility, screening, compliance, provider oversight, analytics, clinical teams, procurement, technology, and leadership decision-making. A provider issue can become a payment issue. A data gap can become an audit issue. A documentation weakness can become a compliance issue. The organizations that are best positioned are the ones that understand how those functions connect and can demonstrate that they are managing risk in a coordinated, evidence-based way.
From a leadership standpoint, leaders of Medicaid organizations can’t simply ask whether they have a program integrity function. We know—and federal and state regulators know—that most organizations do. Instead, leaders need to ask whether that function is designed to withstand increasing scrutiny while it also helps the organization manage risk, support stronger operational performance, and continue to serve Medicaid beneficiaries effectively.
Q: Many organizations are trying to figure out whether this is just another enforcement cycle or something more significant. How are you advising clients to think about the current level of federal scrutiny?
Eisenhower: Every organization should be asking where its greatest vulnerabilities are—whether its controls, oversight processes, policies or operational capabilities may not be sufficient to address them. From there, leaders can prioritize what should be addressed now and what can be phased in.
We’ve worked with agencies and organizations first on the objective assessment of their risk and moved to translate the findings into operational change, which may include developing roadmaps, updated workflows, and& stronger policies, among other actions.
Q: There’s a lot of discussion about moving beyond the traditional pay-and-chase model, but what does a program integrity-first approach look like in practice?
Jennifer Bridgeforth:HMA is working with many state leaders and healthcare organizations that are navigating significant changes across Medicaid financing, eligibility and enrollment systems, and program administration. At the same time, new federal policy and budget constraints are prompting many states to rethink how services are delivered, managed, and financed. Whether a state is redesigning benefits, implementing new eligibility processes, restructuring payment approaches, or pursuing broader delivery system reforms, program integrity considerations need to be embedded into those decisions from day one.
That includes documentation requirements, monitoring protocols, data validation, and accountability structures built into the program design.
It also means aligning oversight efforts with emerging federal and state priorities. We are seeing increased attention on areas such as nonemergency medical transportation, applied behavior analysis, personal care services, durable medical equipment, and behavioral health services, as well as techniques such as evaluation and management coding, and identifying high-volume billing patterns. Medicaid leaders need to design programs and workflows that identify risks earlier, support appropriate access to care, and create feedback loops that strengthen operations over time, reducing reliance on a traditional pay-and-chase approach.
Q: One challenge we hear about frequently is how to strengthen oversight without creating barriers to care. How can organizations strike that balance, particularly in areas like behavioral health and applied behavior analysis (ABA), where access is already strained?
Bridgeforth: That balance is critical. Many of the areas under scrutiny are also in which there is tremendous demand and, in some markets, a shortage of providers. ABA and behavioral health are good examples. The answer cannot be to discourage appropriate access. Instead, organizations need stronger documentation, clearer policies, better training, and a shared understanding of what compliant billing and service delivery look like.
Provider education is one of the most important tools. When providers are asked to document more or differently, it can feel like administrative burden. Education has to explain not only what the requirements are, but why they matter.
Eisenhower: Health plans and providers have a strategic opportunity here. States still need partners to help achieve access goals and improve outcomes. Plans, providers, and vendors that can demonstrate strong program integrity policies and effective oversight can position themselves as trusted partners. They help states pursue access and quality goals with greater confidence that those initiatives will not create unnecessary compliance exposure.
Q: Organizations are investing heavily in analytics and AI capabilities. Where do you see the greatest opportunity for these tools to strengthen program integrity efforts?
Bridgeforth: Advanced analytics and AI are becoming increasingly important for detection and prevention. Real-time monitoring, claims pattern analysis, and predictive tools can help organizations identify risk earlier and take action before issues become larger findings or recoveries. But technology is valuable only if the organization has the governance, workflows, documentation, and case management processes to act on the data that the tools identify.
Cross-program compliance is also important. Many organizations operate across Medicaid, Medicare, Marketplace, commercial, and other public programs. When program integrity is approached at the enterprise level, improvements in one area can strengthen compliance across multiple product lines or programs.
Q: You’ve worked with states and healthcare organizations at very different stages of maturity. What are some of the most common gaps or challenges you’re helping clients address today?
Bridgeforth:We’ve worked with organizations atvery different stages of maturity.For example, we supported an organizational assessment and gap analysis that helped a client identify major opportunities across its program integrity function. The team developed a roadmap organized across seven FWA pillars, identified 52 enhancement opportunities, translated those into 184 key actions, and developed 116 success measures so leadership could monitor progress over time.
HMA and HealthTech Solutions, an HMA Company, also supported a statewide implementation that included electronic visit verification improvements, prepayment analytics, post-payment analytics, and modernization of claims review processes. The effort the state move from manual, reactive processes toward a more proactive model, with insights from post-payment analytics informing prepayment edits that could be updated in weeks rather than months.
Q: If you’re a Medicaid leader looking ahead to the next 12 to 24 months, what should be at the top of your program integrity agenda?
Eisenhower: Many of the steps that reduce program integrity risk are the same steps that help organizations perform better: stronger governance, better data, clearer accountability, more consistent workflows, improved provider relationships, and effective monitoring. The upside is not only avoiding findings or reducing audit exposure. It is also ensuring Medicaid dollars are directed to the right beneficiaries, the right services, the right providers, and the right outcomes.
How HMA Can Help
HMA helps states, health plans, providers, and healthcare organizations assess program integrity risk, strengthen governance and compliance infrastructure, design and implement payment integrity strategies, support provider education, modernize analytics and monitoring, and translate findings into measurable operational improvements. HMA can meet organizations where they are, whether they need a targeted assessment, a phased roadmap, implementation support, data analytics support, or enterprise-wide program integrity transformation.
For more information, go to: https://www.healthmanagement.com/services/our-medicaid-consultants-help-you-develop-innovative-strategies/.
