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Developed with Ben Bach, Director of Professional Services, Submittable.
Submittable provides one platform where rural providers apply, your team reviews and awards, and every milestone, disbursement, and report lives with a complete audit trail behind it. CohnReznick’s federal grants and healthcare compliance specialists have teamed with Submittable to provide both the technology and advisory capability you need to run RHTP funding at scale. Learn more about CohnReznick’s RHTP compliance monitoring and advisory services.
State Rural Health Transformation Programs (RHTPs) will be judged not only by whether they strengthen rural healthcare delivery and expand access to care – but also by how well state leaders can demonstrate accountability for those investments. States must be prepared to show a broad range of stakeholders not only what was achieved, but how decisions were made, risks were managed, and funds were stewarded along the way.
That level of accountability requires states to think beyond traditional audit readiness. RHTPs operate in an environment where funding decisions, program performance, regulatory compliance, public perception, and future funding are closely connected; therefore, states must be able to simultaneously manage programmatic, outcomes-based, compliance, reputational, and continuation-funding risk.
The most effective way to manage these risks is to build accountability into the program from the start. Risk management should be a core design principle, not a separate compliance activity conducted after decisions are made. States that establish strong governance, documentation, performance measurement, monitoring, and transparency processes from Day 1 will be better positioned to demonstrate results, defend decisions, and sustain funding.
RHTPs face scrutiny from every direction
Unlike many traditional grant programs, RHTP initiatives are expected to generate meaningful and measurable improvements in healthcare delivery. State leaders should expect questions throughout the life of the program from stakeholders and sources such as:
- CMS
- Legislators
- Auditors
- Healthcare providers
- Community organizations
- Media
- Taxpayers
Future funding opportunities and long-term program credibility may depend on a state's ability to answer these groups' questions with confidence:
- How funding decisions were made
- Why certain initiatives were prioritized
- How risks were addressed
- Whether public resources were used effectively
- Whether investments are producing intended outcomes
This means accountability cannot be viewed as an activity reserved for funding closeout or periodic reviews. Accountability must be continuously demonstrated throughout program implementation.
Why program management alone is not enough
Program administrators play a critical role in implementing initiatives, managing stakeholders, distributing funding, and achieving program objectives. However, successful implementation and effective oversight are not the same thing.
CohnReznick perspective: A program can be well-managed and still lack the evidence, controls, documentation, and objective validation needed to withstand external review.
As RHTPs evolve, independent compliance monitoring can provide an objective view of whether governance processes are functioning as intended, risks are being identified and addressed, documentation supports key decisions, and performance information remains reliable and defensible.
The monitoring function gives leaders an early-warning system. It can identify emerging issues while corrective action is still practical.
CohnReznick perspective: Rather than focusing solely on compliance requirements, effective monitoring provides leaders with insight into operational risks, control weaknesses, documentation gaps, reporting challenges, and other conditions that may affect long-term program success.
This viewpoint goes beyond “whether requirements are being met” to also help ensure the program can withstand scrutiny and maintain public confidence and credibility.
Submittable Perspective: The Two-Minute Test
A simple self-diagnostic for any RHTP: Pick a single dollar that's been disbursed and trace it back to the application, the score, the reviewer, and the approver – in under two minutes, without emailing anyone.
If that’s possible, the program is audit-ready. If the answer involves opening a spreadsheet and a shared drive, it isn’t yet.
What a scrutiny-ready RHTP looks like
A scrutiny-ready program gives leaders the ability to explain and support key decisions, demonstrate responsible stewardship of public funds, show how risks were identified and addressed, and connect investments to measurable outcomes.
Achieving this level of accountability requires a structured approach to governance: defined approval paths, documentation, data validation, performance measurement, and monitoring evidence that support program activities and decisions.
For example, a state should be able to trace a funding decision from the original application through eligibility review, scoring, approvals, award determinations, budget modifications, monitoring findings, corrective actions, payment decisions, and performance results. When stakeholders ask questions, leaders should be able to quickly explain:
- Why specific applicants, providers, regions, or initiatives received funding
- How eligibility, scoring, approvals, and award determinations were documented
- How risks, exceptions, budget changes, and scope changes were reviewed
- How subrecipient performance, payments, and corrective actions are being monitored
- How program outcomes are being measured, validated, and connected to program objectives
- How records can be retrieved quickly when CMS, legislators, auditors, providers, or the public ask questions
Submittable Perspective: How a gap becomes a finding
A common pattern: Two similar applicants are treated differently, with nothing on record to explain why. It's rarely favoritism; more often, eligibility or scoring criteria lived in reviewers' heads and drifted over the course of a program.
Building the rubric directly into the workflow, so a reviewer can't skip a required field, closes this gap before a reviewer ever finds it.
The hidden risk of information fragmentation
Many organizations continue to rely heavily on spreadsheets, email communications, and disconnected repositories to manage complex grant activities.
While these tools may support day-to-day operations, they can create significant risk when leaders need to swiftly explain decisions, validate outcomes, respond to information requests, or demonstrate accountability.
When critical information resides in multiple locations, even basic questions can require extensive effort to answer. Reconstructing funding decisions, approval histories, performance results, monitoring activities, and corrective actions becomes increasingly difficult as programs mature.
Submittable Perspective: Centralized systems of record help address this challenge by preserving workflow histories, documentation, approvals, version histories, performance data, communications, and monitoring evidence in a consistent and accessible manner.
Submittable Perspective: When the numbers don't match
On one legacy program, the “real” status of awards lived across four different spreadsheets and one staff member's memory. When that person was unavailable, the program stalled.
Leadership was later unable to answer a legislator's simple question – How much has actually been disbursed? – because the numbers disagreed across systems. Approvals made by phone or email to hit a deadline are especially prone to disappearing this way: The decision happened, but it lives in a thread no reviewer will ever see.
Building a scrutiny-ready RHTP
Scrutiny readiness begins with intentional program design.
Before large-scale funding activities begin, states should establish:
- Governance structures with clearly defined decision-making authority and escalation paths
- Independent compliance monitoring to test controls, documentation, and risk response
- Risk identification and risk monitoring processes tied to program milestones
- Standardized documentation and approval workflows
- Subrecipient oversight protocols
- Performance measurement frameworks
- Data validation and reporting controls
- Centralized systems of record
- Corrective action management processes
- Continuous monitoring and transparency practices
When these components operate together, accountability becomes part of the program’s operating model rather than an administrative burden added after key decisions have already been made.
Submittable Perspective: If you build it right on Day 1, the audit takes care of itself.
The path forward
Rural Health Transformation Programs represent one of the most significant opportunities in years to improve healthcare delivery and outcomes in rural communities. But successful implementation requires more than distributing funds and reporting results.
The programs best positioned to succeed over the long term will be those that embed accountability, transparency, independent monitoring, documentation, and risk management into daily operations from the very beginning.
For state leaders, the path forward is clear: assess governance now, validate performance data, and implement independent monitoring before questions arise. The organizations that can clearly explain why decisions were made, how risks were managed, where funds were directed, and what outcomes were achieved will be best positioned to maintain credibility and achieve lasting transformation.
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