GAO wants overhaul of Medicare, Medicaid anti-fraud strategy

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The strategy could help cut down on improper payments in Medicare and Medicaid, which totalyed $95 billion in FY 2016.
The strategy could help cut down on improper payments in Medicare and Medicaid, which totalyed $95 billion in FY 2016.

The Centers for Medicare & Medicaid Services should develop a stronger risk-based anti-fraud strategy for the Medicare and Medicaid programs, a federal watchdog group said Tuesday.

Improper payments within the two programs totaled about $95 billion in fiscal 2016.

The Government Accountability Office, in a new report, notes that CMS's anti-fraud initiatives only “partially align” with the office's fraud risk framework, which offers guidance on creating anti-fraud initiatives. While the agency has also started anti-fraud training programs for stakeholders such as providers, it does not require the same awareness training for agency employees, the GAO wrote.

The report also noted CMS' lack of a fraud risk assessment for Medicare and Medicaid, as well as an anti-fraud strategy for the two programs.

“By developing a fraud risk assessment and using that assessment to create an anti-fraud strategy and evaluation approach, CMS could better ensure that it is addressing the full portfolio of risks and strategically targeting the most-significant fraud risks facing Medicare and Medicaid,” the GAO said.

In response, the Department of Health and Human Services said it plans to develop risk-based anti-fraud strategies for both Medicare and Medicaid after it completes ongoing fraud-risk assessment of the federal healthcare marketplace.

The report was spurred in part by past GAO evaluations that identified both Medicare and Medicaid as being at a high risk for fraud.