The GAO announced this week that The Centers for Medicare & Medicaid Services will need to create a much more rugged risk-based anti-fraud solution for the Medicare and Medicaid programs. Improper payments within both programs totaled about $95 billion in fiscal 2016.
The GAO, in a report published on December 5, 2017, indicated that CMS's anti-fraud objectives merely "partially align" with the GAO's fraud risk framework, which gives guidance on developing anti-fraud initiatives. The report notes that despite the fact that CMS has implemented anti-fraud training programs for stakeholders such as service providers, it does not require equivalent awareness training for agency staff members.
The report also declared that CMS does not have a fraud risk assessment for Medicare and Medicaid, in conjunction with an anti-fraud strategy for both programs.
"By developing a fraud risk assessment and using that assessment to create an anti-fraud strategy and evaluation approach, CMS could better ensure that it is addressing the full portfolio of risks and strategically targeting the most-significant fraud risks facing Medicare and Medicaid," the GAO stated.
In response, HHS said it will develop risk-based anti-fraud strategies for both Medicare and Medicaid after it completes its ongoing fraud-risk assessment of the federal healthcare marketplace.
The report was driven in part by earlier GAO assessments that determined both Medicare and Medicaid as having a great risk for fraud, waste, and abuse.
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