On March 5, the House of Representatives Energy and Commerce Subcommittee sent letters to California, Colorado, Massachusetts, Maine, Nebraska, New York, Oregon, Pennsylvania, Vermont, and Washington to investigate reports of Medicaid fraud. The purpose of the investigation is to assess the extent of fraud in state Medicaid programs and understand what states are doing to address any issues and protect Medicaid integrity.
What is health care fraud?
Health care fraud is intentionally submitting false information to receive payment. This can include billing for services that were not performed.
What does data show about Medicaid fraud?
Fraud against Medicaid is mostly committed by providers. Every year the Department of Justice and Department of Health and Human Services, Office of the Inspector General, publish a report on their efforts to hold bad actors accountable. The report accounts for bad actors across Medicare, Medicaid, and other Federal health care programs.
In their December 2024 report there is a list of different kinds of fraud and those who have been identified and prosecuted. No Medicaid beneficiaries are listed. Those who were convicted of fraud include ambulance service providers, durable medical equipment suppliers, diagnostic labs, nursing homes, pain clinics, pharmacies, physical therapists, physicians, and substance use treatment providers.
This means that the victims of Medicaid fraud are enrollees, honest providers, and taxpayers.
What safeguards are there against Medicaid Fraud?
As a joint venture between states and the federal government, there are many levels of checks on fraud against Medicaid. Both the states and the federal government have agencies responsible for preventing, detecting, and prosecuting Medicaid fraud. These include Centers for Medicare and Medicaid Services (CMS), Department of Justice (DOJ), the Federal Bureau of Investigation (FBI), Office of the Inspector General (OIG) at the federal level. At the state level, there are Medicaid Fraud Control Units (MFCUs). Additionally, Congressional oversight agencies (Government Accountability Office) and committees as well as state Medicaid agencies, Managed Care Organizations (MCOs), and state legislative oversight agencies and committees play a role in safeguarding from fraud against Medicaid.
In Summary
Fraud does exist. However, it is largely protected and/or prosecuted. Those who commit fraud against Medicaid are mainly providers, not beneficiaries/enrollees.
Encourage confidence to act
