The Congressional Budget Office has said that while anti-fraud efforts agencies have launched to better manage payments in Medicare and other government-sponsored health programs are laudable, they impact only a portion of improper payments made in such programs.
It said that notable anti-fraud efforts in those programs of recent years include the HHS Health Care Fraud and Abuse Control program, the joint HHS-Justice Health Care Fraud Prevention and Enforcement Action Team, and the HHS Fraud Prevention System that uses data analytics to facilitate prepayment review of claims, focusing on the most problematic claims and billing practices. But CBO agreed with GAO’s position that there is no reliable gauge of how much money is at stake in total.
One commonly used indicator is the amount of settlements or recoveries in those programs. Individuals and businesses repaid the government more than $4 billion in 2013 in restitution and penalties for fraud in the Medicare, Medicaid and CHIP programs, and since 1997 that figure is about $26 billion, or about 0.3 percent of the total amount spent on those programs in that time, CBO said. However, thatdoes not account for fraud that goes undetected, CBO said in a report describing various types of anti-fraud efforts directed by law or administrative order in recent years.
The report also examined another indicator, estimates of improper payments. According to HHS, Medicare overpays 9.3 percent per year, Medicaid about 5.8 percent and CHIP 7.1 percent. More than 90 percent of that in each case consists of overpayments, CBO said, and “improper payments include many payments that are not fraudulent—for example, some for which the paperwork was incorrect, although the service itself was proper.”A measure of improper payments similarly does not include undetected fraud, said the report, which is here: http://www.cbo.gov/sites/default/files/cbofiles/attachments/49460-ProgramIntegrity.pdf
