GAO urges action to prevent Medicaid fraud

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There are significant deficiencies in the Medicaid program's ability to detect and prevent fraud, waste and abuse, according to a report from the Government Accountability Office, which outlines key challenges states face in maintaining program integrity.

As Medicaid continues to expand in scope, particularly with recent changes tied to the COVID-19 public health emergency, these findings raise concerns about the sustainability of the program and the effectiveness of oversight mechanisms, according to the report.

WHAT'S THE IMPACT

GAO identified systemic issues that impair Medicaid's ability to root out fraudulent activities. According to the report, many states rely on outdated or insufficient technology to monitor for irregular billing and other suspicious patterns in claims data. Furthermore, state Medicaid agencies often lack the resources or workforce to properly investigate the volume of potential fraud cases that emerge.

Despite various state and federal efforts, Medicaid's program integrity measures have not kept pace with the complexity of modern fraud schemes. Fraud schemes have evolved to exploit loopholes in billing practices, particularly in areas such as managed care organizations (MCOs), which represent a significant portion of Medicaid spending. These shortcomings place an enormous financial burden on the program.

State Medicaid programs frequently fail to share vital data with one another or with the Centers for Medicare and Medicaid Services (CMS), further hindering national efforts to combat fraud, the report said.

The financial impact of fraud, waste and abuse in Medicaid is significant. HHS estimates that improper payments in Medicare and Medicaid, which include fraud but also unintentional errors, accounted for $100 billion in fiscal year 2023 alone.

GAO outlines several recommendations aimed at improving Medicaid's program integrity, including better coordination between state and federal agencies, stronger enforcement of existing fraud-prevention policies, and an overhaul of outdated technology systems. Key suggestions include expanding the use of advanced data analytics to identify unusual billing patterns and improve fraud detection in real-time.

The report also recommends that CMS issue clearer guidance to states on how to implement robust fraud-prevention strategies. Currently, states have considerable flexibility in how they administer Medicaid, which can result in wide variability in fraud detection capabilities. More standardized approaches may lead to more consistent and effective oversight across states.

Another critical area for improvement is managed care oversight, with MCOs often operating with less scrutiny than fee-for-service programs. GEO suggested CMS should focus more attention on MCOs, particularly by ensuring that these organizations have the capacity and incentive to prevent and detect fraudulent activity.

Healthcare leaders, policymakers, and technology vendors will need to collaborate to ensure Medicaid can meet the growing healthcare needs of millions of low-income Americans while maintaining financial sustainability, GAO said.

THE LARGER TREND

As Medicaid transitions to value-based care models, in which providers are incentivized based on patient outcomes rather than service volumes, fraudulent billing can become even more problematic, as it can distort quality metrics, leading to misallocation of resources and inappropriate financial incentives.

Correction: This story has been updated to reflect that the information came from the Government Accountability Office. Healthcare Finance News apologizes for previously misstating the source of that data.

Jeff Lagasse is editor of Healthcare Finance News.
Email: jlagasse@himss.org
Healthcare Finance News is a HIMSS Media publication.