Program integrity leaders hold two responsibilities at once. Fraud in human services programs is real and it hurts people. When a provider bills for services never delivered, the person who needed those services goes without, public trust erodes, and money that could have supported others is lost. Some schemes also exploit the people enrolled, using their identities or cutting their care. DHS has publicly described a stronger program integrity effort under its Office of Inspector General, including heightened scrutiny of services it has designated as high risk, revalidation of providers, pauses on new enrollment in some services, payment withholds and third-party billing reviews. Leaders in this work need to take fraud seriously.
Careless enforcement also causes harm. An enforcement action against a provider can abruptly end services for people who had nothing to do with any wrongdoing. Broad sweeps can burden honest small providers, many of them owned by or serving immigrant, Black, Indigenous or disabled communities, with paperwork they cannot absorb. Public statements that link a community to fraud can stigmatize people who receive services lawfully and discourage eligible families from seeking help. Mistaken findings, when they happen, cost people money, reputation and care. None of this argues for less oversight; it argues for better-designed oversight.
A first discipline is precise language. The Centers for Medicare and Medicaid Services treats improper payments and fraud as related but distinct. An improper payment can come from an error, a missing signature, a misunderstanding of a rule or a system problem. Fraud involves intentional deception. Waste and abuse are different again. Treating every error as fraud leads to disproportionate responses and poisons relationships with providers who could have fixed a problem with guidance.
The U.S. Government Accountability Office Fraud Risk Management Framework gives leaders a structure. It has four components: commit to combating fraud by creating a culture and structure for managing fraud risk; assess by planning regular fraud risk assessments and building a risk profile; design and implement a strategy with specific control activities; and evaluate outcomes and adapt. The framework emphasizes prevention and asks managers to set a fraud risk tolerance. It openly acknowledges that managers may weigh the program's mission, such as getting help to people quickly, against lowering the likelihood of fraud. Holding both goals in view is part of the method, not a compromise of it.
