Why Digitized Plans of Care Could Transform Medicaid Program Integrity

July 31, 2026

Andy Allison, Vice President, Consulting and Client Services

Medicaid oversight has a timing problem. For years, Medicaid fraud, waste, and abuse (FWA) efforts have chased questionable claims after the money has already left the system. But a major shift may be on the horizon.

Recent federal actions and interoperability mandates suggest a new era is coming. Early signs indicate the Centers for Medicare and Medicaid Services (CMS) is preparing states for a future where long-term care oversight becomes digital, connected, and rooted in continuous analysis. If this vision becomes a reality, it represents a potential turning point in the modernization of Medicaid long-term services and supports (LTSS). We are moving from looking backward to seeing exactly what is happening right now.

The Core Problem: Medicaid Plans of Care Aren’t Structured Data

In modern healthcare, nearly every clinical and financial activity traces back to digital documentation that is structured, transmittable, and analyzable. Hospital stays include diagnosis that can also be found in claims for other services such as physician visits and prescription drugs. Medical records, ADT data, and other digitized information can be combined to create extended episodes of care and to match the need for care (e.g., diagnoses) with the provision of care (e.g., procedure codes and DRGs). Long-term care is a different story. Often the documentation for non-institutional LTSS and other care for those with intellectual and developmental disabilities, physical disabilities, and for children with developmental or behavioral health needs is not fully digitized, making modern care planning, program design, and oversight difficult.

The clinical need for these services is often described in individualized plans of care (POC), which document the exact services Medicaid members should receive.¹ Many agencies still store these vital documents in disconnected formats. Many remain handwritten or scanned. These plans effectively function as the prescription or blueprint for services across areas such as:

Home and Community-Based Services (HCBS) such as personal attendant care
Applied Behavior Analysis (ABA) and other related services for children
Services for those with intellectual and developmental disabilities (I/DD)
School-based services supported by individualized educational plans (IEPs)

These services represent some of Medicaid’s largest and fastest-growing expenditures and they are often packaged together in combination with medical care and pharmacy to address Medicaid beneficiaries’ complex and varied needs. Yet states often lack the ability to digitally match authorized services, delivered services, billed services, diagnoses, and member needs across all of these systems and care plans.

That gap has significantly limited sophisticated FWA oversight, coordinated care management, and deeper operational insight across LTSS.

How Digitizing POCs Could Transform Care

The foundation for change is already here. CMS-0057 interoperability mandates and the potential for digitization of POCs are becoming twin catalysts for a new era of connected Medicaid oversight.²^,3 POCs include rich details of LTSS member needs, their preferences and tendencies, vulnerabilities and strengths, advice on member communication, member history, a comprehensive view of the care and services provided to that individual, and points of contact like key family members and house staffing.

As states expand interoperability and modernization efforts into long-term care POCs, states could begin correlating digitized POCs with:

Electronic Visit Verification (EVV) data
Claims
Provider billing patterns
Medical diagnoses
Clinical and functional assessments
Utilization trends
Care coordination records
Interoperability data streams

That creates the foundation for a far more advanced form of Medicaid management and oversight.

Instead of simply identifying suspicious claims after payment, states could begin enabling a more comprehensive approach to Medicaid program integrity and program planning:

Continuous surveillance using analytics, automation, and AI-accelerated anomaly detection
Earlier identification of services delivered outside authorized care plans
Detection of utilization patterns inconsistent with diagnoses, assessments, or member needs
Recognition of excessive hours, duplicative services, or billing patterns that diverge from peer norms
Expert-driven investigation coordinated across clinical, policy, program integrity, and operational teams
Interdisciplinary solutioning to address root causes, strengthen oversight, and improve program performance

EVV Was Only the Start for Digital Care Coordination and Oversight

CMS and state Medicaid agencies have increasingly emphasized EVV as a foundational program integrity capability for home- and community-based services. EVV helps confirm that caregivers were onsite delivering authorized services and can enable reduction of billing FWA.⁴

But EVV alone only does not necessarily ensure the most appropriate volume of services, nor optimal coordination of services. For that, linkage of digitized EVV data to claims, to assessments of need—and to digitized POCs—would be ideal. In-home caregivers often have access to digitally imaged POCs now, but service providers do not. Providing medical caregivers access to an LTSS member’s POC will provide critical context and important member information to help ensure that caregivers provide the right care and communicate it appropriately to members and LTSS caregivers. Imagine the value of a provider knowing a patient’s systemic struggles with certain types of medication, or their eating habits, when treating a chronic medical condition.

The same information that provides such invaluable context and enables a step-change improvement in care coordination for LTSS members will also provide analytic context for states. The structured nature of fully digitized POCs coupled with EVV’s improved transactional detail (vs. claims and encounters) for time of delivery, supervisor and caregiver identification, and specific GPS location, could, if integrated and capably analyzed, enable dramatic improvements in states’ understanding of care patterns, member experiences, member outcomes, workforce dynamics, service gaps, as well as substantially-improved detection and assessments of FWA.

The next logical step involves connecting visit data to digitized care plans and broader interoperability frameworks so states can analyze whether:

The right services were delivered, and with the right duration, as authorized
The care aligned with diagnoses and member needs
Billing patterns match expected care pathways
The content and evolution of a member’s care plan matches observed patterns of care and is consistent with diagnoses and other member characteristics
Care planning and optimized service use improve member outcomes

This integration key sources of data is where Medicaid oversight fundamentally evolves from simple attendance-tracking to assessment of improvement opportunities and the deep validation of improper utilization that can follow.

The Big Opportunity in Waste Prevention

Former Medicaid directors consistently tell us that waste—not intentional fraud—poses the largest financial challenge. That distinction matters deeply.

“Waste” is a much broader term than fraud or abuse. It refers to the overutilization or inappropriate utilization of services resulting in unnecessary costs. Unlike fraud, waste is not an intentional program violation, and unlike abuse it is not necessarily inconsistent with established standards of care. Waste may look like a provider authorizing an approvable but excessive amount of therapy, a legal but unnecessarily expensive type of therapy, or a provider prescribing medications where other forms of care would work better.⁵

Waste often stems from unclear or undisciplined diagnoses, porous definitions of need, shifting standards of care and, at the individual level, poor coordination, outdated care plans, inconsistent documentation, and fragmented systems. Identifying waste is rarely straightforward. It often requires iterative collaboration among program experts, policy leaders, data analysts, providers, and other stakeholders to interpret policy intent, refine definitions of appropriate utilization, and distinguish legitimate variation from unnecessary spending. Manual review limitations make this work difficult to scale and can leave significant inefficiencies undetected. Recovering funds after improper payments occur is an expensive and difficult process and, critically, requires as a starting point the establishment of clear, enforceable, and transparent standards of care. Often these conditions are not met for LTSS and other non-clinical care. Taking the steps to prevent unnecessary spending upstream delivers a much larger impact than a pay-and-chase emphasis on recovery for these types of services.

Manual review limitations make this work difficult to scale and can leave significant inefficiencies undetected. Recovering funds after improper payments occur is an expensive and difficult process and requires the establishment of clear, enforceable, and transparent standards of care.

By prioritizing enhanced analytics and digitization, we can create a smarter Medicaid operating environment. The real opportunity lies in building proactive systems, rather than simply catching bad actors after the fact. It is about driving better health and human services outcomes while protecting vital state resources.

Moving Beyond Elementary Oversight

Current analytic approaches often rely heavily on rules-based and retrospective methods:

Duplicate claims checks
Static thresholds
Post-payment reviews
Simple edit logic

While these approaches remain necessary, they fall short in complex HCBS and LTSS environments.

As states modernize LTSS data, the next generation of FWA analytics must go further. We can implement cross-program pattern analysis and longitudinal member utilization modeling. Agencies can use AI-assisted anomaly detection and near real-time monitoring to review care plan alignment. Medicaid oversight is beginning to evolve from retrospective audits to connected operational intelligence.

Medicaid Is Moving Toward Connected Oversight

The emerging CMS direction reflects a broader evolution already underway across the entire Medicaid landscape:

Interoperability requirements are expanding
Data exchange expectations are rising
AI-enabled analytics are becoming operationally viable
States are under increasing fiscal pressure
Program integrity is shifting from recovery to prevention

Long-term care has historically lagged behind other parts of healthcare in digitization and analytic maturity. That reality may finally be changing.

As Medicaid continues moving in this direction, care plans may become more than simple documentation artifacts. They will serve as foundational data assets that power smarter oversight and real-time care management.

For states, the implications extend far beyond fraud detection. They point toward a more connected, measurable, and highly proactive Medicaid system. Act now to digitize and operationalize care plan data. Position your state to detect issues earlier, enable fully-informed caregiving, reduce unnecessary spending, and build the next generation of Medicaid program integrity.

For more information about digitizing plans of care, modernizing LTSS oversight, and advancing Medicaid program integrity, contact us.

Sources:

CMS.gov, n.d., Home and Community-Based Services: Requirements for Person-Centered Plans for Home and Community-Based Services, https://www.cms.gov/files/document/hcbs-care-plan-req-booklet-102815pdf
CMS.gov, Jan. 17, 2024, CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), https://www.cms.gov/newsroom/fact-sheets/cms-interoperability-prior-authorization-final-rule-cms-0057-f
Missouri Department of Mental Health, n.d., eLTSS Health Information Data Exchange Project, https://dmh.mo.gov/dev-disabilities/eltss
Medicaid.gov, CMS Centers for Medicare & Medicaid Services, Center for Medicaid & CHIP Services, n.d., Leveraging Electronic Visit Verification (EVV) to Enhance Quality Monitoring and Oversight in 1915(C) Waiver Programs, https://www.medicaid.gov/medicaid/downloads/evv-enhance-quality.pdf
NAMD National Association of Medicaid Directors, Jun. 27, 2025, Why Did They Do It That Way? Program Integrity, https://medicaiddirectors.org/wp-content/uploads/2025/06/NAMD-Why-did-they-do-it-that-way-program-integrity-06-27-25.pdf