Program Integrity Is Boring (If You’re Doing It Right): From Pay-and-Chase to Everyday Oversight
By PPL on October 2, 2026
The best program integrity efforts don’t look like investigations or audits. They look like… nothing. Done well, PI is drama-free and happens continuously as part of everyday operations.
What Proactive Program Integrity Looks Like
Traditional approaches to program integrity (PI) can feel a bit frantic. You run a report, find anomalies, and launch an urgent audit or investigation to figure out what happened. This pay-and-chase merry-go-round is inefficient and time-sucking, but it doesn’t have to be this way.
Moving modern program integrity checks upstream, so they happen as early as point of service, is critical to ensure anomalies and inconsistencies are identified early and often. Combined with shared PI ownership, this approach can help avoid the urgent audits and establish a system of everyday integrity.
Thinking of PI as a proactive, ongoing effort — something embedded throughout the entire claim cycle rather than a reactive, post-payment cleanup exercise — can yield substantial savings. States moving PI into daily operations are seeing positive effects, without the need for more restrictive rules or tougher enforcement.
‘Boring’ items like eligibility checks, payment validation, and utilization monitoring are evolving from ‘in the trenches’ administrative steps to becoming PI and cost avoidance tools in their own right.
During last year’s session at the HCBS Conference, panelists from Arkansas and Pennsylvania all described moving in this direction. The stories were different, but the message was consistent: when PI is woven throughout daily workflows, problems become easier to spot and fix. And that means less disruption to everyone involved, including participants and caregivers.
Why Upstream Program Integrity Checks Work Better Than Post-Payment Audits
We’re not going to pretend that moving PI upstream means you’ll never have to do another post-payment audit. No system is perfect, and from time-to-time things fall through the cracks. But you can start to see pay–and-chase as a rare exception, instead of ‘what we always do.’
By the time an audit surfaces a problem, services have been delivered, the claim has been paid, and multiple stakeholders are likely to get dragged into the messy adjustment/recoupment shuffle. You’re in for hours of administrative grunt-work, appeals, and avoidable hassle (sometimes for participants who did everything right)!
When compared to prospective actions, industry analysis suggests that retrospective recovery has lower success rates and higher administrative cost per dollar recovered.
Front-end and ongoing checks can short circuit all of this.
When…
- Eligibility is confirmed at the point of service and multiple points beyond.
- Payments are only made when specific rules and conditions (including things like Electronic Visit Verification (EVV) check-ins) are met.
- Utilization is checked before the participant receives service.
…more improper payments are avoided.
What Does Continuous Program Integrity Look Like?
We often think of data as something to drive decisions. A report, a dashboard, investigative findings. We look at data, see a problem, then go fix it. But in evolved PI models, the data doesn’t just pinpoint errors; it shows the path to avoid them.
During that same HCBS panel, states described using data continuously rather than periodically. For example, Arkansas’ Independent Choices program runs multiple checks to highlight eligibility changes and utilization issues as early as possible:
Tami Rogers
Arkansas DHS
We check eligibility on the front end, midstream of the enrollment process, and again prior to a client beginning to receive services. These are very quick checks that keep us moving the client into self-direction while catching issues early.
Pennsylvania’s Office of Long-Term Living takes a similar approach, using automated system checks to catch issues before a claim is paid:
Liz Metcalf
Pennsylvania Office of Long-Term Living
Our MIS functions as a gatekeeper. So if there is no service authorization, or if the participant doesn’t have eligibility, or there’s no EVV record for services that require it, the claim just automatically denies.
In these models, program integrity is less a standalone initiative and more a thread woven throughout normal, daily operations. With multiple PI waypoints throughout service delivery, issues surface early when they’re still small and easy to resolve.
The Best Program Integrity Is Quietly Effective
One clear theme from the panel was that effective program integrity doesn’t need to be overt:
“Eligibility is one area where we’re really in a solid place. It’s extremely rare for services to be authorized, let alone billed or paid out when the participant or worker is ineligible.”
– Liz Metcalf
When systems are in place and ticking over smoothly, you see fewer fire drills, less pay and chase, and minimal disruption to stakeholders. Program staff can spend less time reacting to crises and more time managing operations.
Quiet doesn’t mean accidental. These programs are the result of deliberate design: upstream controls, continuous monitoring, and shared responsibility.
“Our workflow has been automated, and it has been amazing for us to be able to [see] changes in close to real time. Any eligibility updates can be caught and changed, which is just so far from where we came from.
… we have a lot of reports, and it’s well worth it because it helps us capture mistakes that occur along the way—in enrollment, in the program. It has been extremely, extremely beneficial.”
– Tami Rogers
Why Program Integrity Matters for Growing Self-Directed Care Programs
Self-directed care (SDC) programs are growing fast, and we’re still fighting a perception battle. A lot of people think that the core idea of SDC — participants can hire friends and family members — is intrinsically a huge fraud, waste, and abuse risk. Simultaneously, as more participants rely on these programs to support their very way of life, tolerance for disruption is low.
Integrity models that lean on post-payment cleanup don’t scale well under these conditions. Operational integrity is required. When multi-point safeguards are built into the fabric of daily workflows, state agencies can focus on program delivery, and their programs can just work.
In other words, PI doesn’t have to feel like enforcement. When done well, it feels like success.
This is the second in a series of four stories about program integrity within self-directed care.
