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Fraud In Medicaid Program

The House Oversight and Government Reform Committee’s Subcommittee on Government Operations recently held a hearing to examine the program integrity efforts of different Federal Agencies, who were vulnerable to fraud and abuse. The committee held discussions with the witnesses from Social Security Administration (SSA), Department of Treasury (DOT), Department of Health and Human Services (HHS), the Office of Management and Budget (OMB), and several other federal agencies. Reports say that this program received positive responses from the members.

Medicare Fraud Prevention System (FPS) was highlighted in the hearing from the Deputy Chief Financial Officer for HHS, Sheila Conley. The predictive analytics software system has been active since 2011, and it helps agencies to target their audits and investigations. Approximately 4.5 million claims are being analyzed by the FPS system daily in order to look for red flags. The testimony from Conley indicates that an 11.5 percent return on investment was generated by the FPS in the year 2015.

Conley’s testimony also revealed the intentions of HHS to continue their use of prior authorization in order to prevent fraud in the Medicare program. Furthermore, the Centers for Medicare and Medicaid Services (CMS) have considerably increased their use of prior authorization in the last few years. The testimony from Conley clarifies that HHS is looking to continue expanding the use of this process to prevent and eliminate fraud in Medicaid program.

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House Oversight And Government Reform Committee

CMS used to take advantage of the provider enrollment process in order to screen for bad actors. Conley’s testimony talked about the importance of this process and highlighted the need to continue this process. The effectiveness of fraud recovery efforts were also discussed by Conley, particularly mentioning the recovery efforts through Recovery Audit Contractor (RAC) program.

The members of the committee clearly wanted CMS to focus more on improving Medicare fraud prevention, rather than just relying on the “pay and chase” tactics. And it is evident by Conley’s testimony that CMS is intending to increase use on all their tools including provider screening, prior authorization, and FPS to prevent fraud in Medicaid program. Reports indicate that this is consistent with what CMS told HBMA during their meeting, which was held at the CMS headquarters earlier this year.

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