黑料正能量 Note: As the recent Government Accountability Office report indicated, states could be doing more to prevent Medicaid fraud, particularly in programs and services that operate outside of managed care. Insurance regulation can fix some of these issues, but there is typically a disincentive for states to target ongoing systemic problems because it may reveal internal fraud and abuse.
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CMS Not Doing Enough to Fight Medicaid Fraud, GAO Finds
Heartland; Jehadu Abshiro, 6/15/2015
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Medicaid, the national government health care program meant to help provide health care for the impoverished, is riddled with fraud, according to a Government Accountability Office (GAO) study that analyzed Medicaid payment data from the year 2011 in four states: Arizona, Florida, Michigan, and New Jersey.
The agency found about 8,600 Medicaid beneficiaries received payments in two or more of the four states that year, in violation of federal law, totaling at least $18.3 million. It also discovered Medicaid payouts to approximately 200 deceased beneficiaries, totaling about $9.6 million.
GAO also found approximately 50 health care providers billed Medicaid even though they were excluded from the program for patient abuse and fraud. Those bills amounted to approximately $60,000.
GAO recommends the Centers for Medicare and Medicaid Services (CMS) do more to prevent fraud by providers and patients by providing new guidance to states about screening Medicaid beneficiaries more thoroughly and giving the states full access to the federal government鈥檚 records on Medicaid providers.
鈥淓very dollar [stolen] is committing a crime,鈥 said Mara Mellstrom, legislative manager at the Foundation for Government Accountability. 鈥淭his is no different from stealing from your neighbor.鈥
Amount of Fraud Unknown
Almost 70 million Americans are currently enrolled in Medicaid, according to a report released by the U.S. Department of Health and Human Services in February. The report states Medicaid spending grew by 6.1 percent in 2013, to $449.4 billion, and constituted 15 percent of national health expenditures.
CMS projects health care expenditures financed by federal, state, and local governments will account for 48 percent of national health care spending and a total of $2.5 trillion by 2023. This is a 44 percent increase from 2012, when total government health care spending was approximately $1.2听trillion.
鈥淯ltimately, due to the nature of the enrollment program, it is difficult to tackle the fraud,鈥 Mellstrom said. 鈥淭he depth of Medicaid fraud is truly unknown, since so many states do the minimum in addressing the issue from the get-go.鈥
If states used a better screening approach or took a more active role in catching scammers, they could achieve a 2 to 5 percent savings in Medicaid spending, Mellstrom says.
鈥淚t鈥檚 about bringing welfare programs into the 21st century, and it鈥檚 really [about] making use of your resources,鈥 Mellstrom said. 鈥淲e need to backtrack and see how we got here.鈥
Misplaced Incentives Cited
States don鈥檛 have much incentive to flush out waste, fraud, and abuse in programs like Medicaid, and this leads to misallocated resources, says Thomas Miller, a resident fellow at the American Enterprise Institute.
鈥淚mprovised coverage doesn鈥檛 provide the care promised and it鈥檚 not particularly well-administered, and therefore some of that money gets diverted into other places,鈥 Miller said.
Some states are moving toward a private-sector managed-care approach that enables slightly better policing of fraud, Miller says.
鈥淭here鈥檚 been mixed results in that,鈥 Miller said. 鈥淚t鈥檚 probably a little bit better, but it doesn鈥檛 mean the problem has been solved.鈥
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