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Medicare And Medicaid Program

The Subcommittee on Oversight and Investigations conducted a hearing last month to analyze frauds and abuse within the federal healthcare programs. The hearing was chaired by Tim Murphy (R-PA- 18), and included three witnesses; Dr. Shantanu Agrawal (Deputy Administrator and Director of Center for Program Integrity, CMS, HHS), Mr. Seto J. Bagdoyan (Director, Audit Services, Forensic Audits and Investigative Service, GAO), and Ms. Ann Maxwell (Assistant Inspector General, Office of Evaluation and Inspections, OIG, HHS). The core focus of the hearing was to improve the measures to prevent frauds in the Medicare and Medicaid programs.

Dr. Agrawal noted that most of the improper healthcare payments are not a scam in fact, but occur because of the medical billing and coding errors. The committee members also compared the commercial insurers with the Federal programs. Rep. Murphy was found to be among the most critical improper payment rate in fee-for-service Medicare, and said that incorporating more commercial practices would help reduce improper payments. Many other representatives also shared similar views on comparing the improper payments in commercial sector to that in Medicare and Medicaid.

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The committee members and witnesses also stressed that the state authorities should take more responsibility for enforcing fraud prevention measures. Dr. Agrawal highlighted that CMS had provided the states with advanced ways to prevent federal healthcare frauds such as background checks and direct helplines. However, Ann Maxwell expressed that state authorities were facing operational problems and funding issues while trying to implement Medicare and Medicaid program integrity. Maxwell further said that the suggested guidelines were not that simple to implement as what some committee members considered it to be.

OIG released their Semiannual Report to the House a couple of weeks after the hearing, which highlighted their efforts to prevent healthcare payment frauds and abuse in the first half of FY 2016. The report stated that OIG managed to recover around $2.77 billion so far in 2016, which is around $1 million more than what was achieved in the same period last year. OIG representatives also said in the report that around 1,662 providers were excluded from participating in the federal health programs until now.