Fraud, waste, and abuse are serious concerns in any publicly funded program. Medicaid dollars should pay for authorized services that are delivered. But protecting Medicaid does not mean that every person receiving services, every family member, and every home care provider should be treated as though they are a potential source of fraud or treated as if we are on parole. Before Virginia adds another restriction, another verification requirement, another layer of monitoring, or another administrative hurdle to consumer-directed care, there should be a simple requirement:
Show us the evidence. What is the documented scope of fraud, waste, and abuse specifically within Virginia's consumer-directed home care program? How many cases have been identified? How much money has been lost? What percentage of consumer-directed expenditures does that represent? What types of violations are occurring?
And most importantly: Which specific policy change addresses which documented problem?
We already have oversight in Virginia. To be clear, Consumer-Directed Care is not an honor system. Virginia's consumer-directed care program already has multiple layers of accountability. Individuals must first qualify for Medicaid and be assessed for services. Medicaid then authorizes the type and amount of care they may receive; the consumer does not simply choose their own hours. Attendants must document their work hours and the authorized tasks performed. Those shifts are reviewed and approved by an Employer of Record (EOR), and a Fiscal/Employer Agent processes the approved information before Medicaid-funded wages are paid.
A home care provider cannot simply claim, “I worked these hours,” and receive Medicaid payment. Oversight and verification are already built into the system. The question is not whether Medicaid should have accountability. The question is how much additional oversight is necessary, what documented problem each new requirement is solving, and when oversight becomes overregulation.
So before adding still more restrictions, Virginia should answer the following question. What existing safeguard failed and what evidence demonstrates that the proposed new restriction will fix that failure?
It is important to demarcate between and not confuse the following issues of improper payments, errors, and fraud: These terms matter. A paperwork error is not automatically fraud. A missed EVV clock-in is not automatically fraud. A corrected timesheet is not automatically fraud. A family caregiver working significant hours because a person has significant disabilities is not automatically fraud. Program-integrity policies should distinguish intentional deception from administrative errors, technological failures, documentation problems, and legitimate utilization of authorized services. Otherwise, Virginia risks building policy around suspicion rather than evidence.
Is the Response Proportionate to the Problem?
This is the question policymakers should be required to answer. If Virginia can demonstrate a specific vulnerability in consumer-directed care, then the Commonwealth should address that vulnerability. But the response should be targeted and proportionate. If the problem involves improper billing, strengthen billing controls. If the problem involves inadequate documentation, improve documentation. If particular providers or entities demonstrate suspicious billing patterns, investigate those patterns. If enforcement is inadequate, strengthen enforcement.
But Virginia should not automatically impose increasingly burdensome requirements across an entire population of legitimate caregivers and Medicaid members without demonstrating that those requirements address a documented problem.
Who Bears the Cost of Increased Oversight?
Administrative requirements are not free simply because they do not appear as a line item in the Medicaid budget. Someone absorbs that cost. The home care provider spends additional time documenting. The Employer of Record spends additional time reviewing. The person with a disability or older adult navigates additional requirements. Families deal with corrections, applications, exceptions, technology failures, and appeals. Finally, when administrative requirements become too difficult to navigate, the ultimate cost may be losing workers from an already strained home care workforce, which is already happening.
Program integrity should protect the Medicaid program, not make legitimate care harder to provide.
Questions Virginia Should Answer Publicly: Before additional restrictions are imposed on consumer-directed home care, DMAS and policymakers should disclose:
1. How much documented fraud exists?
Provide Virginia-specific figures for substantiated fraud, waste, abuse and improper payments within consumer-directed personal care.
2. Where is it occurring?
Distinguish consumer-directed services from agency-directed care and other Medicaid programs rather than relying on broad Medicaid statistics.
3. What kind of problem is it?
Separate intentional fraud from billing errors, documentation deficiencies, late submissions, EVV discrepancies and other administrative noncompliance.
4. Which policy addresses which problem?
For every new requirement, identify the specific program-integrity vulnerability it is intended to address.
5. What is the expected benefit?
How much fraud, waste, abuse or improper payment is each policy projected to prevent?
6. What is the administrative cost?
Measure the additional burden on providers, Employers of Record, families and Medicaid members.
7. What happens if the policy causes harm?
Track delayed wages, rejected shifts, caregiver departures, service disruptions and appeals alongside any claimed program-integrity savings.
There Is Another Oversight Question: It is integral to recognize the need to examine DMAS's program-integrity infrastructure, not merely the people receiving and providing Medicaid services. During the 2026 budget process, lawmakers considered funding for an outside vendor to assess program-integrity efforts at DMAS and its contracted managed-care organizations, including fraud detection, data analytics, auditing, referrals, enforcement, training, provider enrollment, utilization management and system controls.
That raises an important principle: Oversight cannot flow in only one direction. If home care providers are monitored, DMAS's implementation should be monitored. If providers must document their actions, the Commonwealth should document the results of its policies. If providers are held accountable for compliance, agencies and contractors administering these programs should also be held accountable for errors, delays, failed systems and harmful implementation.
There continues to be support for protecting Medicaid from fraud, support accountability measures and ensuring public dollars pay for services that are provided.
What is being opposed is using the language of “fraud, waste, and abuse” as a blank check for policies that place increasingly broad burdens on legitimate home care providers and the people who depend on them without first demonstrating the problem those policies are designed to solve.
Show us the data! Show us the problem! Show us how the policy solves it! Show us that the cure will not cause more harm than the problem it was supposed to fix.