How a Single Fiscal Intermediary Strengthens Program Integrity in Self-Directed Care
By PPL on August 20, 2026
Self-directed care is built on choice. Participants choose who supports them, how care fits into their life, and who they trust to help them stay home and independent. It’s a choice worth protecting.
Protecting that choice takes the right infrastructure. One of the most important factors in strengthening program integrity is how a program’s fiscal intermediary (FI) function is structured.
What Gets Missed in a Fragmented System
When a program runs through dozens, or hundreds, of separate FIs, each vendor holds its own slice of the data — its own enrollment records, timesheets, and billing systems, often in different formats. No single entity has a clear view across the full population, which means patterns that cross vendor boundaries are difficult to identify. Assembling the full picture often means retroactively reconciling data from multiple vendors.
A single statewide FI closes that gap. Because one entity processes every timesheet against one consistent set of rules, a caregiver billing an implausible number of hours across multiple consumers, for example, can be flagged as part of the standard process — before payment goes out and Medicaid is billed.
Related: How Strong Fiscal Intermediaries Protect Self-Directed Care Programs
What a Multi-Vendor System Looked Like in New York
Before 2025, New York’s Consumer Directed Personal Assistance Program (CDPAP) ran through more than 600 separate FIs. Data was siloed. Enrollment and billing practices varied widely from one vendor to the next. And patterns that mattered were difficult to detect.
After consolidating to a single, statewide FI, that changed. With one unified view of the program, it became possible to identify things that had been invisible before, including excessive hours billed across multiple consumers, billing for care after a consumer’s death, and overlapping shifts. Within months of the transition, for example, PPL identified more than 1,000 personal assistants submitting timesheets for more than 20 hours a day across three or more consecutive days — including over 60 who did so for 10 or more consecutive days. Excluding consumers approved for around-the-clock care, the estimated annual Medicaid impact reaches $10 million.
The transition wasn’t without growing pains — consolidating hundreds of vendors into a single system was a substantial operational undertaking, carried out on a compressed timeline. But the trade-off produced program integrity gains that weren’t possible under the previous structure.
The previous system wasn’t lacking good intentions. It was lacking the infrastructure to see the whole picture — something a single FI is built to do.
Why This Matters For States and Policymakers
For states evaluating how to structure self-direction programs: Consolidation isn’t just an administrative decision. It’s a program integrity decision — one with measurable effects on how well a state can protect the people it serves and the public dollars that enable home and community-based services.
A capable, accountable FI doesn’t get in the way of choice. It’s what makes choice safe to offer at scale.
Related: How Self-Directed Care Programs Control Fraud, Waste, and Abuse
