Understanding FWA and the HCBS Vulnerability
There is a lot of focus in the healthcare market currently on fraud, waste and abuse. But let’s start with a more basic question: What is fraud, waste, and abuse in healthcare? Simply stated, fraud is an intentional lie to get money. Waste is the overuse of services or supplies. Abuse is the result of poor care that leads to unnecessary costs. Altogether, FWA has led to the loss of hundreds of billions of dollars from public medical programs, which often leads to tighter budgets and members not being able to get appropriate care.
While media coverage often highlights sensational examples of fraudulent billing schemes, inflated reimbursement practices, or providers operating under questionable business arrangements, these stories represent only part of a much larger conversation. The challenge facing Medicaid programs today is not only identifying fraud but implementing effective safeguards that prevent bad actors from entering the system in the first place.
Home and Community-Based Services (HCBS) have been identified as one of the service categories with the potential for widespread fraud within these Medicaid-funded programs due to the large number of members they serve. In addition, they provide the majority of care in the community, using non-clinicians and their services are often misunderstood or can look different according to how they are tailored to meet a member’s needs.
A March 2026 Health Affairs Forefront article cautioned policymakers against conflating isolated instances of wrongdoing with systemic fraud, noting that improper payments are frequently the result of administrative or documentation errors rather than intentional deception. The authors emphasized that HCBS remains a critical component of the nation’s long-term services and supports system, helping older adults and individuals with disabilities remain safely in their homes and communities while often avoiding more costly institutional care. (Tavares, Barkoff, Rosenbaum, & Cohen, Health Affairs Forefront, March 2026)
An Upstream Approach to Program Integrity
In response to concerns about FWA in the HCBS setting, state Medicaid agencies have employed numerous program integrity tools, including provider screening, background checks, Electronic Visit Verification (EVV), claims monitoring, audits, and Medicaid Fraud Control Units. These safeguards are designed to identify vulnerabilities and address fraudulent activity without disrupting access to legitimate services.
This perspective aligns with Telligen’s philosophy that the most effective fraud prevention strategy begins “upstream,” before nefarious activity reaches claims payment. Rather than relying solely on downstream detection and recovery efforts,
Telligen’s HCBS Compliance and Certification Program is designed to identify risk indicators early in the provider enrollment and certification process. The goal is straightforward: prevent fraud before Medicaid dollars are spent, preserving resources for the members who depend on these services and reducing financial exposure for states and taxpayers.
Through a structured review schedule, provider applications are evaluated using a systematic process designed to identify inconsistencies, compliance concerns, and indicators of potential risk. Screening calls, market prioritization strategies, and pattern identification methodologies allow Telligen to assess providers before they begin delivering services. By recognizing potential vulnerabilities, Medicaid agencies reduce the likelihood of future fraud investigations, payment recovery, and disruptions to member care.
A key advantage of Telligen’s model is our position as a conflict-free, independent vendor. While many states conduct these activities internally, an external review process provides an objective perspective focused on quality and compliance. This independence supports consistent decision-making and allows states to strengthen oversight without creating additional administrative burden. Equally important, the process is not solely about excluding problematic providers. Telligen works to establish clear expectations and compliance standards in alignment with state administrative code and regulatory policy that help legitimate providers succeed.
As scrutiny of HCBS programs continues to increase, organizations that demonstrate strong program quality and compliance oversight practices in advance of strong program integrity protocols will be valuable partners to state Medicaid agencies. HCBS remain essential and cost-effective services that can prevent institutionalization and allow individuals with complex needs to live productive, fulfilled lives in the community, but protecting that investment requires proactive oversight. By focusing on prevention, quality, compliance and early identification of risk, and conflict-free review processes, Telligen helps keep bad actors out of the system, safeguard Medicaid resources, and ensure services remain available for the individuals who need them most.