GAO: FEHB is vulnerable to at least 10 other forms of fraud, and OPM’s “fraud risk profile” addresses only one of those—the potential for health care providers to submit false claims to insurance carriers. Image: The Image Party/Shutterstock.com
By: FEDweek StaffThe risk of fraud against the FEHB program goes well beyond the issue of ineligible persons being covered as family members, but OPM’s efforts to manage fraud risks do not account for most of them, the GAO has said.
That issue has drawn the most attention regarding potential fraud against the program, with a 2022 GAO report and several inspector general reports saying that enrollments of ineligible persons is costing the program $1 billion or more annually, costs that are passed on to both enrollees and the government in the form of higher premiums.
A new GAO report says that two recommendations made earlier remain open; meanwhile, the recently enacted budget reconciliation law ordered fuller effort and provided funding for OPM to carry it out.
However, it said that a larger issue is that the FEHB is vulnerable to at least 10 other forms of fraud, and OPM’s “fraud risk profile” addresses only one of those—the potential for health care providers to submit false claims to insurance carriers.
Other risks cited by the GAO include: the sharing of benefit cards resulting in benefits to ineligible persons; physicians referring patients to an entity in which they or a family member have a financial interest; false or misleading claims due to exaggerating or hiding the quality of a product or service; kickbacks; and failure to maintain records to show that claims meet health benefit requirements.
Also: gifts or sponsorships to physicians to encourage the use of a specific product or service; incomplete or inaccurate reports submitted to OPM by the carrier; non-compliance with provider eligibility requirements; and risks arising from disclosure of personally identifying information and health information.
The report did not estimate the potential cost to the program of those types of fraud.
The report also said that while an internal “risk management council” has been overseeing OPM’s anti-fraud efforts, it does not follow all best practices such as engagement of stakeholders with expertise. Also, as of April “OPM officials stated that the agency is in a transition period, and it is uncertain whether the RMC will continue to lead these efforts.”
It said OPM agreed with recommendations to clarify which entity will lead fraud risk management efforts; assess the inherent fraud risks facing the FEHB program; and involve relevant stakeholders in the process.
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