On June 25, 2014, the U.S. House Energy and Commerce Subcommittee on Oversight and Investigations held a hearing, “Medicare Program Integrity: Screening Out Errors, Fraud, and Abuse.” During the hearing, subcommittee members heard testimony from administration officials from the Centers for Medicare and Medicaid Services (“CMS”), the Office of Inspector General (“OIG”), and the Government Accountability Office (“GAO”). The Deputy Administrator and Director of the Center for Program Integrity, Dr. Shantanu Agrawal, spoke on behalf of CMS; the Deputy Inspector General for Investigations, Gary Cantrell, spoke on behalf of the OIG; and Kathleen M. King, Director of Health Care spoke on behalf of the GAO. 

Dr. Agrawal described CMS’s efforts to reduce fraud, waste and abuse. According to Dr. Agrawal, “CMS is using a multi-faceted strategy to target all causes of waste, abuse and fraud that result in inappropriate payments by shifting towards prevention-oriented activities.”  Dr. Agrawal stated that CMS is applying the following three operational principles to guide all of its initiatives: (1) aiming to achieve operational excellence in addressing the full spectrum of integrity causes, in taking swift administrative actions, and in the performance of audits, investigations and payment oversight; (2) providing leadership and coordination in program integrity efforts across the health care system; and (3) focusing on impacting the cost and appropriateness of care across health care programs. In Dr. Agrawal’s testimony, he described some of CMS’s efforts to reduce fraud, waste and abuse, including: (1) strengthening provider enrollment; (2) ensuring proper and accurate claims payment; (3) facilitating leadership and coordination across the health care system; and (4) improving payment data transparency.

Mr. Cantrell described the OIG’s efforts to improve Medicare oversight and reduce fraud, waste and abuse. In particular, Mr. Cantrell’s testimony provided an overview of current health care fraud trends and challenges that impede effective oversight, as well as recommendations on how to address such trends and challenges. According to Mr. Cantrell, “[i]mplementing these recommendations could result in billions of dollars saved and more efficient and effective programs.”

Ms. King focused on the progress made to date and the important steps the GAO recommends CMS to take to further reduce Medicare fraud.  The GAO found that, although CMS has strengthened provider and supplier screening, more can be done to improve Medicare program integrity. Similarly, the GAO believes that further improvements to prepayment and postpayment claims review may better identify or recover payments. Additionally, the GAO recommends that CMS address identified vulnerabilities to reduce fraud. According to the GAO, CMS’s current mechanisms do not adequately address such vulnerabilities. The GAO recognizes that “CMS has taken some important steps to identify and prevent fraud” but cautions that CMS “must continue to improve its efforts to reduce fraud, waste, and abuse in the Medicare program.”

During the hearing, subcommittee members underscored the problems with current systems, asked questions regarding Medicare fraud, and highlighted the importance of combating such fraud.

A webcast of the hearing is available here.

Posted by Jennifer K. Shanley

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