Every Medicaid dollar should come with accountability: Was the beneficiary eligible? Was the service authorized and delivered? Did the spending accomplish its purpose? Taxpayers deserve answers. So do the patients whose care depends on the program.
The administration has made a bold promise to prioritize rooting out fraud, waste, and abuse, with notable progress already. Every dollar stolen, improperly paid, or needlessly spent is a dollar unavailable for legitimate patient care for our most vulnerable citizens. Protecting Medicaid’s resources is essential to protecting the people the program was created to serve.
But accountability cannot begin only after the money is gone. We can all agree the status quo “pay and chase” model is ineffective. Instead, we need systems designed to confirm eligibility, prevent improper payments, document services, and identify problems before they become expensive failures.
That requires modernization with a clear purpose: stronger safeguards, better information, and measurable results.
Eligibility verification is one part of that work. States should have accurate, timely information to determine who qualifies for coverage and resolve discrepancies promptly. Payment oversight is another. States should be able to verify provider qualifications, identify questionable billing, and establish whether an authorized service was actually delivered.
Care coordination addresses a related problem: spending that fails to produce the high-quality, community-based services patients need. Services rendered can still represent poor value when services are duplicated, referrals disappear, or manageable conditions deteriorate because nobody follows up.
These problems require different responses. Fraud demands investigation and enforcement. Administrative errors demand correction. Fragmented care demands better coordination. Modern infrastructure should support all three, with clear accountability for each.
Consider a rural patient who needs regular treatment but lacks reliable transportation. A referral alone does not solve the problem. Someone must arrange the ride, confirm that it happened, and determine whether the patient received care. Without that follow-through, an apparent solution may exist only on paper while the patient’s condition worsens.
Too often, healthcare providers, insurers, government agencies, and community organizations work through disconnected systems. Each may see one piece of a patient’s situation, while nobody can reliably track the entire process. That creates opportunities for duplication, missed care, and spending that cannot be adequately explained.
A closed-loop referral system can help close those gaps by tracking a referral through acceptance, service delivery, and follow-up. When connected to appropriate documentation and a clear longitudinal record of services, it can give administrators a clearer record of what was authorized, what occurred, and what remains unresolved.
That visibility supports accountability. A referral should not be counted as a completed service. A completed service should not automatically be counted as a successful outcome. States need to measure each step and distinguish activity from results.
Analytics can also help identify unusual patterns, overlapping services, and patients who may need earlier intervention. Those findings should guide review and follow-up. A flagged claim requires examination; a prediction requires validation. Technology is useful when it strengthens sound judgment and makes decisions easier to audit.
Missouri offers a practical example of a program that is working. Its Transformation of Rural Community Health, or ToRCH, program connects rural hospitals and community organizations to coordinate community-based care and address documented health-related needs. The program uses technology from Unite Us, a technology provider that integrates health and community-based care, to coordinate referrals and reimbursement to ensure the needed service or care was provided to the individual.
In its published case study, Unite Us reported a 19.6 percent increase in individuals with controlled blood pressure and an 18 percent increase in behavioral-health follow-up after emergency department visits across participating hospitals and clinics. These reported improvements are encouraging. They should also be evaluated alongside program costs, comparison data, and sustained patient outcomes.
The lesson is straightforward: modernization should be judged by what it delivers. Demonstrating fewer duplicate payments, more completed services, better health outcomes, and lower avoidable costs is evidence of value.
States should apply that standard to technology vendors as rigorously as they apply it to healthcare providers. Contracts should establish clear performance measures, protect patient information, support secure information exchange, and allow officials to hold contractors accountable when results fall short. Any claim of savings should account for the cost of the technology and the services it supports.
Better coordination can also help beneficiaries manage their health more effectively. Timely care, appropriate follow-up, and practical help reaching treatment can support personal responsibility and reduce the risk of avoidable crises. Those interventions should remain tied to documented needs, authorized services, and measurable benefits.
Policymakers should pursue enforcement and modernization together. Strengthen eligibility controls. Ensure services are being delivered to the right people by credible partners. And build the capacity to determine whether legitimate spending is producing worthwhile results.
Taxpayers deserve a Medicaid program that can account for its expenditures. Patients deserve one that follows through on their care. Modernization earns its place when it delivers both.
Andrew Langer is President of the Main Street Foundation