How Strong Fiscal Intermediaries Protect Self-Directed Care Programs

senior woman sitting in a wheel chair at a desk, being helped by a woman with dark brown hair. they are looking at papers together

Programs that let people direct their own care are under a level of scrutiny they haven’t faced before. Headlines raise fair questions about fraud, waste, and abuse in Medicaid, and self-directed care is caught up in that conversation.

But what that conversation tends to skip is the critical piece that makes these programs work: the fiscal intermediary (FI).

The Value of Self-Direction

Self-direction gives people control over their care. They choose who supports them, how their day unfolds, and what works best for their life. For so many families, that’s more than something nice to have. It’s what makes staying independent at home possible.

None of that has to come at the expense of accountability. Done right, the two work hand in hand to make self-direction work safely and reliably, with everyone’s best interests in mind: the people receiving care, the caregivers providing it, and the public dollars that make it all possible. Here’s what that looks like in practice.

Protection Starts Before a Payment Is Made

The most effective fraud, waste, and abuse controls aren’t enabled after something goes wrong. They’re built into every step of the process, before a caregiver provides any care and before a single dollar is paid.

PPL, an FI for self-direction programs across 18 states, enables these controls starting at enrollment — verifying that each caregiver is eligible to work, confirming their relationship to the Medicaid member, checking any required health or training standards, and completing federal work-authorization requirements, including Form I-9. A participant’s authorized service hours are set through clinical assessments conducted by the state and health plans, and PPL validates every subsequent payment against those authorizations.

A rules-driven payroll engine, capable of processing more than one million timesheets in near real time, applies automated edits that catch and prevent payment for irregularities such as overlapping shifts, hours beyond what’s authorized, or a caregiver logging time for multiple people at once. When the data flags a potential integrity issue, PPL refers it to the health plan or to the appropriate oversight body.

What This Looks Like in New York’s Consumer Direction Program

New York’s Consumer Directed Personal Assistance Program (CDPAP) — for which PPL is the single statewide FI — is one of the largest self-direction programs in the country and offers a useful example of what strong FI infrastructure delivers.

For example, looking at timesheets submitted over a three-month period, PPL was able to identify a pattern of caregivers logging an implausible number of hours — in many cases, more than 20 hours a day across multiple consecutive days. Patterns like these are unsustainable and can be indicative of potential fraud, waste, or abuse — and while there may be a reasonable explanation, flagging these patterns allows for targeted review to determine where investigation is warranted and confirm that services are being delivered as needed. The potential excessive hours identified in this analysis represent an estimated annual Medicaid impact of up to $10 million, when exclusions are made for consumers approved for around the clock care.

This is why strong controls matter. Consistent enforcement of timesheet approval helps ensure that payment is tied to care that has actually been reviewed and confirmed, protecting consumers, caregivers, and the integrity of the program. PPL works closely with the New York State Department of Health, local departments of social services, and health plans to review these cases and determine how much of this spending reflects potential fraud, waste, or abuse, and our compliance team reviews and acts on allegations that are credible. These activities represent a program actively protecting the people it serves and the integrity of the system that supports them.

The Layers That Make This Possible

None of this happens through one single control. It’s the result of multiple layers working together:

Enrollment screening verifying a caregiver is eligible to work, confirming their relationship to the Medicaid member, checking required health and training standards, and completing federal work-authorization requirements, including Form I-9.

Authorization validation, where every hour billed is checked against the participant’s approved spending plan — or approved time — in real time, so costs can’t exceed what the state, local department of social services, and health plan have authorized before payment.

A unique caregiver identifier, tracing each caregiver across EVV, payroll, and billing so their activity can be monitored program-wide to confirm it complies with state and federal rules.

Electronic Visit Verification (EVV) timekeeping technology capturing the details of each visit and requiring the participant to review and approve the time worked before it’s paid.

Automated prepayment edits, validating each timesheet against program rules to catch irregularities like overlapping shifts, hours beyond what’s authorized, or attempted billing after a participant’s death, and holding them for review.

Cross-population analytics surfacing patterns at population scale, such as excessive hours, unusual billing trends, and EVV non-compliance.

Why Does This Matter?

People deserve to direct their own care without sacrificing the protections that keep a program trustworthy. Strong FIs make that possible without getting in the way of choice, flexibility, or independence. They’re what allows those things to work safely, at scale, for everyone involved.