MEDICAID PAYMENT INTEGRITY: ADDRESSING IMPROPER PAYMENTS

 

Improper payments and fraud continue to be chronic and costly difficulties for Medicaid and other government-funded programs. The GAO defines improper payments as payments that should not have been made or that were made in an incorrect amount (including overpayments and underpayments) under statutory, contractual, administrative, or other legally applicable requirements. According to the GAO, the federal government loses between $233 billion and $521 billion annually to fraud alone.

Since FY 2003, executive branch agencies have reported increasing improper payment estimates totaling approximately $2.7 trillion. In fiscal year 2023 alone, federal agencies reported $236 billion in improper payments across 71 programs. While the FY 2023 estimate represents an $11 billion downturn from the previous year, this reduction is credited to temporary flexibilities granted during the COVID-19 PHE. These measures, such as relaxed eligibility requirements for Medicaid beneficiaries and providers, minimized instances of improper payments under the altered criteria.

Medicaid's High-Risk Status

Medicaid has been on the GAO's High-Risk List since 2003 due to vulnerabilities in payment integrity. In FY 2023 alone, HHS estimated that Medicaid improper payments totaled $50 billion. According to HHS, the leading contributors to these payments are missing or insufficient documentation, particularly in validating beneficiary eligibility and payments to ineligible beneficiaries or ineligible services.

Actions and Legislative Efforts to Reduce Improper Payments:

CMS has made some progress in identifying these susceptibilities. For instance, CMS collaborated with states and audit contractors to improve oversight of healthcare companies contracted to manage healthcare services for Medicaid beneficiaries. Investigations rose from 16 between 2016 and 2018 to 893 between 2019 and 2021, uncovering significant overpayments.

Over time, several legislative efforts have been aimed at curbing fraud, waste, and abuse. Despite these pieces of legislation, Medicaid continues to lose billions of dollars because of payments made in error. The measures directed by the legislation are costly and primarily revolve around compliance and reporting rather than reducing improper payments.

Remaining Challenges:

The GAO identified several areas for improvement, including:

Provider Screening and Enrollment Requirements

The GAO suggested CMS review state compliance with screening and enrollment requirements and monitor noncompliance yearly. While CMS has provided technical assistance, further action is needed to assess and address all states' compliance.

Medical Reviews for Improper Payments

The GAO advised CMS to strengthen Medicaid's medical review processes to identify the root causes of improper payments and implement corrective actions. As of March 2024, HHS disagreed with this recommendation and does not plan to implement it.

Compliance with the Payment Integrity Information Act of 2019 

Medicaid was deemed compliant with PIIA criteria in FY 2023. However, it was not fully compliant in fiscal years 2021 and 2022.


Considerable gaps remain in addressing improper payments and fraud. By fully implementing GAO recommendations and enhancing oversight, federal agencies and programs like Medicaid can better safeguard taxpayer dollars, reduce waste, and improve operational efficiency. Nevertheless, to prevent improper payment rates from rising even more, agencies should look to innovate data solutions to identify and prevent fraud, waste, and abuse.

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MEDICAID IMPROPER PAYMENTS TOTALED $50.3 BILLION IN 2023

 

A new audit by the GAO reveals that the government suffered a significant loss of $236 billion in 2023 because of improper payments. Medicaid and Medicare alone made up 43% of these payments, with Medicaid's improper payments totaling $50.3 billion. These findings underscore the urgent need to address improper payments, which often come from eligibility errors and out-of-date data systems, not widespread fraud and abuse.

By law, Medicaid functions as the payer of last resort, meaning it covers healthcare expenses only after other third-party payers satisfy their obligations. However, discovering these third-party payers has become increasingly difficult as the program expands because of insufficient access to usable eligibility data. The lack of accurate eligibility data has resulted in billions in improper payments for Medicaid plans.

When Medicaid plans discover improperly paid payments, they utilize a "pay and chase" process to recover funds. This approach has built a multibillion-dollar post-payment recovery industry, but unfortunately, for payers of last resort, only 20 cents on the dollar is recouped.

The challenge to identify liable third-party payers has persisted for years, exacerbated by the absence of tech capable of correctly pinpointing active and accurate "other health insurance". Despite legislative efforts and federal initiatives to curb improper payments, the problem has continued, resulting in Medicaid's inclusion on the Government Accountability Office's high-risk list for twenty consecutive years.

How can payers of last resort minimize improper payments?

To mitigate the need for post-payment recovery, Medicaid payers must gain access to timely and accurate eligibility data. Leveraging ePrescribing infrastructures presents a promising solution, as they house some of the most complete and current data on patients' health insurance coverage.

Recognizing this potential, Syrtis Solutions has created ProTPL, a technology-based solution that utilizes ePrescribing eligibility data to help Medicaid plans proactively identify primary payers. ProTPL makes it possible for Medicaid plans to avoid erroneous claims costs upfront by using proprietary logic and advanced matching algorithms, improving the claims process for all stakeholders involved.

Syrtis Solutions' ProTPL addresses the root cause of improper payments by using better data and applying it to avoid erroneous claims payments. ProTPL ultimately decreases costs and improves efficiency in Medicaid claims management.

Click here and learn more. 

$50.3 BILLION IN MEDICAID IMPROPER PAYMENTS

 

Medicaid improper payments have caused the healthcare program to be on the Government Accountability Office's High-Risk List since 2003. The GAO's list identifies government-funded programs that involve significant resources and offer important services to the public that are susceptible to fraud, waste, abuse, and mismanagement. For two decades, Medicaid and other CMS programs have struggled with these improper payments, and it's costing billions. A common misunderstanding is that Medicaid improper payments stem primarily from fraud when, actually, the vast majority arise from insufficient documentation and eligibility errors. CMS issued the following improper payments fact sheet for fiscal year 2023 this month.

Here are the improper payment rates for CMS’ programs in Fiscal Year 2023:

• The Medicare Fee-for-Service (FFS) estimated improper payment rate was 7.38%, or $31.2 billion, marking the seventh consecutive year this figure has been below the 10% threshold for compliance established by improper payment statutory requirements.[1] The 2023 rate is not statistically different from the 2022 Medicare FFS estimated improper payment rate of 7.46%.
• The Medicare Part C estimated improper payment rate was 6.01%, or $16.6 billion. CMS made significant methodology changes during the past two years’ reporting cycles (FY 2021 and FY 2022), and FY 2023 establishes a baseline; however, it is not statistically different from the 2022 estimated improper payment rate.
• The Medicare Part D estimated improper payment rate was 3.72%, or $3.4 billion. This estimated improper payment rate incorporates various methodology refinements. These comprehensive changes contributed to an increase in the FY 2023 estimated improper payment rate, and the rates for FY 2023 are not comparable to previous years.
• The Medicaid improper payment rate (comprised of reviews in 2021, 2022, and 2023) was 8.58%, or $50.3 billion, a significant decrease from the 2022 reported rate of 15.62%. Of the 2023 Medicaid improper payments, 82% were the result of insufficient documentation. These payments typically involve situations where a state or provider missed an administrative step and do not necessarily indicate fraud or abuse.
• The Children’s Health Insurance Program (CHIP) improper payment rate (comprised of reviews in 2021, 2022, and 2023) was 12.81%, or $2.1 billion, a substantial decrease from the 2022 rate of 26.75%. Of the 2023 CHIP improper payments, 68% were the result of insufficient documentation, which is generally not indicative of fraud or abuse.
• The improved performance in the national Medicaid and CHIP improper payment estimates reflect 1) reviews that accounted for certain flexibilities afforded to states during COVID-19, such as suspended eligibility determinations and reduced requirements around provider enrollment and revalidations, which were typically included in the PERM reviews prior to the COVID-19 PHE; and 2) improved state compliance with other program requirements. While it is unclear how much the decrease is attributable to the PHE flexibilities versus improved state compliance, it appears that the PHE flexibilities had an impact on lowering the rate. Please note that the data does not capture any effects of the PHE unwinding, as these will be included in future report periods.
• The 2023 improper payment rate for the Advance payment of the Premium Tax Credit (APTC) program for the Federally Facilitated Exchange (FFE) for Benefit Year 2021 (January 1 to December 31, 2021) was 0.58% or $272 million. CMS found that the FFE properly paid an estimated 99.42% of total outlays, or $46 billion, in Benefit Year 2021.

 

Learn more from the whitepaper "Improper Payments - Medicaid's Billion Dollar Problem"

 

What You Need to Know:

The Payment Integrity Information Act of 2019 defines significant improper payments as either:

(i) improper payments greater than $10 million and over 1.5% of all payments made under that program, or

(ii) improper payments greater than $100 million.

• The 2023 HHS Agency Financial Report provides the improper payment rates for the Medicare Fee-for-Service (FFS), Medicare Part C, Medicare Part D, Medicaid, Children’s Health Insurance Program (CHIP), and Affordable Care Act Health Insurance Exchange Advance payment of the Premium Tax Credit (APTC) programs.
  1. Insufficient documentation
  2. The documentation provided for the items or services billed did not sufficiently demonstrate medical necessity.
• The vast majority of improper payments occurred in situations where there was an unintentional payment error or a reviewer could not determine if a payment was proper because of insufficient payment documentation from a state, provider, or the FFE.
• While fraud and abuse are one cause of improper payments, not all improper payments represent fraud or abuse. Improper payment estimates are not fraud rate estimates.
• Improper payments can result from a variety of circumstances, including:
  • Items or services with no documentation.
  • Items or services with insufficient documentation.
  • Or, with respect to Medicaid, CHIP, and the FFE, no record of the required verification of an individual’s eligibility, such as income.
• Proper payments occur when there is sufficient documentation to support payment in accordance with the program payment requirements. Two examples of proper payments include:
  • Payments where CMS or the state appropriately maintained documentation of an eligibility verification requirement and appropriately determined eligibility based on program eligibility and payment requirements.
  • Payments where sufficient documentation was provided to support medical necessity in accordance with program payment requirements.

 

Improper Payment Measurements:

 

Medicare Fee-for-Service

• CMS developed the Comprehensive Error Rate Testing (CERT) program to estimate the Medicare Fee-for-Service (FFS) program improper payment rate.
  • The CERT program reviews a statistically valid stratified random sample of Medicare FFS claims to determine if they were paid properly under Medicare coverage, coding, and billing rules. If these criteria are not met, the claim is counted as an improper payment.
  • The majority of Medicare FFS improper payments fall into two categories:
    1. Insufficient documentation
    2. The documentation provided for the items or services billed did not sufficiently demonstrate medical necessity.

1. 1.  

Medicare Part C

• CMS estimates the Part C Medicare Advantage (MA) improper payments using the Part C Improper Payment Measure (IPM) methodology.
  • CMS calculates an annual capitated payment for each Medicare beneficiary enrolled in an MA Organization (MAO) based on diagnosis data previously submitted to CMS by the MAO. The diagnosis data are used to determine risk scores and calculate risk-adjusted payments to MAOs for their enrollees. Inaccurate or incomplete diagnosis data may result in improper payments made to MAOs.
  • CMS conducts the annual Part C IPM activity to estimate the improper payments for the Medicare Part C program due to unsubstantiated risk adjustment data.
  • Part C IPM reviews the medical record documentation for a statistically valid stratified random sample of Medicare Part C enrollees to ensure the diagnosis data used to determine payment to the MAO are present and in accordance with CMS rules and regulations.
• The majority of Part C improper payments fall into three categories:
  1. The MAO’s supporting documentation fails to substantiate the beneficiary diagnosis data submitted for payment
  2. Invalid documentation, such as illegible documentation.
  3. Missing documentation.

 

Medicare Part D

• CMS estimates the Part D Prescription Drug Benefit improper payments using the Part D IPM methodology.
  • The Medicare Part D IPM primarily focuses on analyzing Prescription Drug Events (PDEs). Each PDE record includes details about a specific prescription transaction, such as the drug prescribed, the quantity, and the associated costs. The PDE data are not the same as individual drug claim transactions but are summary extracts using CMS-defined standard fields.
• CMS conducts the annual Part D IPM activity to identify improper payments caused by invalid and/or inaccurate drug claims. These errors could lead to adjustments in beneficiaries’ benefit phases, reinsurance subsidy payments, and CMS payments. Drug claims selected for audit are evaluated using prescription record data and supporting documentation provided by the Part D Plan Sponsors.
• The Part D IPM reviews a statistically valid stratified random sample of PDEs to ensure the supporting documentation validates payment attributes and processing was in accordance with CMS rules and regulations.
• Part D improper payments fall into three major categories:
  1. Missing or invalid documentation, such as missing authorization.
  2. Drug discrepancies, such as the drug dispensed contains a different active ingredient than the drug prescribed.
  3. Drug pricing discrepancies.

 

Medicaid & Children’s Health Insurance Program (CHIP)

• CMS estimates Medicaid and CHIP improper payments using the Payment Error Rate Measurement (PERM) program.
  • The PERM program uses a three-year, 17-state rotation, meaning each state is reviewed once every three years, and each cycle measurement includes one-third of all states. The most recent three cycles (for 2023, that is, 2023, 2022, and 2021) are combined to form each year’s overall national rate.
  • PERM ensures a statistically valid random sample representative of all Medicaid and CHIP payments matched with federal funds.
  • Medicaid and CHIP improper payment data released by CMS are based on reviews of whether states are implementing their Medicaid program and CHIP in accordance with federal and state payment and eligibility policies.
  • The national Medicaid and CHIP improper payment rates are based on reviews of the FFS, managed care, and eligibility components of a state’s Medicaid and CHIP program in the year under review.
• In addition, the PERM program combines individual state component estimates to calculate the national component estimates. National component rates and the Medicaid and CHIP rates are weighted by state size, such that a state with a $10 billion program is weighted more in the national rate than a state with a $1 billion program.
• The majority of Medicaid and CHIP improper payment findings are the result of insufficient or missing documentation.

 

ACA Exchange Advance Payment of the Premium Tax Credit

• CMS estimates Advance payment of the Premium Tax Credit (APTC) improper payments using the Exchange Improper Payment Measurement (EIPM) program.
  • The EIPM program currently measures improper payments for the Federally Facilitated Exchange (FFE). The improper payment measurement methodology for State-based Exchanges is under development.
  • The EIPM program measures improper payments based on a statistically valid random sample representative of all health insurance applications with APTC payments processed by the FFE.
  • APTC improper payment estimates are based on reviews of the FFE compliance with requirements surrounding payment and eligibility determinations.
• The majority of APTC improper payments are tied to manual eligibility verifications.
• This year is the second year the EIPM program is reporting APTC improper payment information. CMS is reporting improper payment information for calendar year 2021 in the fiscal year 2023 HHS Agency Financial Report.
• The APTC program represents the first of two potential[2] payment streams for the overall Premium Tax Credit program. The second payment stream relates to additional Premium Tax Credit amounts claimed by taxpayers at the time of their tax filings, referred to as “Net Premium Tax Credits” (hereafter, “Net PTC”). That is, total Premium Tax Credit outlays (or credits) are equal to APTC payments plus Net PTC claims. The Internal Revenue Service (IRS) measures improper payments associated with Net PTC claims, and for Calendar Year 2021 reported[3] Net PTC claims of $1.97 billion, improper payments of $512.71 million, and an improper payment rate of 26.04%. The combined APTC and Net PTC improper payment estimate is $784.46 million out of $48.47 billion total Premium Tax Credit outlays/claims, or 1.62%. Treasury and HHS are reporting this combined error rate for the Premium Tax Credit program as a whole in both departments’ Agency Financial Reports.
  • State Medicaid Provider Screening and Enrollment Data and Tools: CMS shares Medicare data to assist states with meeting Medicaid screening and enrollment requirements. For instance, CMS shares the Medicare provider enrollment record via the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) and offers a data compare service allowing states and territories to rely on Medicare’s provider screening in lieu of conducting a separate state screening, which is particularly helpful to states when conducting revalidation.
  • Enhanced Assistance on State Medicaid Provider Screening and Enrollment: CMS provides ongoing guidance, education, and outreach to states on federal requirements for Medicaid provider screening and enrollment. CMS also assesses provider screening and enrollment compliance, provides technical assistance, and offers states the opportunity to leverage Medicare screening and enrollment activities.

 

CMS/State Collaboration on Improper Payments:

• CMS collaborates with states in many ways to share information and help to ensure they maintain the proper documentation to demonstrate that payments are being made correctly. Examples include:
  • Medicaid Eligibility Quality Control (MEQC) Program: Under MEQC, states design and conduct pilots to evaluate the processes that determine an individual’s eligibility for Medicaid and CHIP benefits. States have flexibility in designing pilots to focus on vulnerable or error-prone areas as identified by the PERM program and state. The MEQC program also reviews eligibility determinations that are not reviewed under the PERM program, such as denials and terminations.
• Medicaid Integrity Institute (MII): CMS offers training, technical assistance, and support to state Medicaid program integrity officials through the MII. More information is located at the Medicaid Integrity Institute website.

More information on CMS’ Improper Payments Measurement Programs can be found at https://cms.gov/ImproperPayments.

To view the HHS Agency Financial Report, visit: http://hhs.gov/afr.

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IMPROPER PAYMENTS KEEP MEDICAID ON GAO'S HIGH-RISK LIST

 

The GAO just recently published its updated High-Risk List. The update is part of the biennial High-Risk Series started in 1990 that identifies government operations susceptible to fraud, waste, abuse, and mismanagement. The current report marks the twentieth consecutive year that Medicaid has made the cut. According to the GAO, CMS must strengthen fiscal oversight of program expenditures to reduce improper claims payments and ensure that program resources are spent correctly.

Fiscal year 2022 was a demanding period for Medicaid as the program was dealing with the ongoing social and financial impact of the COVID-19 Public Health Emergency (PHE). Enrollment increased by almost 20 million people between 2020 and 2022. Consequently, initiatives to strengthen program integrity were often superseded by the necessity to act in response to the PHE and support states. In FY 2022, Medicaid provided close to 82 million beneficiaries with healthcare at an estimated cost of $516 billion.

High-Risk Segments of the Medicaid Program

The GAO's report pinpointed the following three segments that comprise the overall high-risk of the Medicaid program:

1. Improper payments hit $81 billion in FY 2022
2. The use of state-directed payments and supplemental payments
3. Limited oversight of Medicaid expenditures and utilization data

Recommendations from the GAO

Along with identifying segments of high-risk, the GAO's report also endeavors to help resolve these susceptibilities by making recommendations. Currently, seventy recommendations associated with Medicaid program integrity remain open. The GAO's recommendations to CMS for 2023 are:

• Expand its evaluation of states' implementation of provider screening and enrollment requirements and, for states not fully compliant with the requirements, annually monitor their implementation progress;
• improve oversight of Medicaid procurements;
• collect adequate provider-specific information from states on Medicaid payments to providers, including supplemental payments and the sources of funds states use to fund their share of the payments, and specify what criteria should be used to ensure that Medicaid payments at the provider level are economical and efficient;
• perform an assessment and take steps to ensure that resources to oversee state-reported expenditures are sufficient and allocated according to risk; and
• continue efforts to assess and improve T-MSIS data and articulate specific plans and associated time frames for using these data for broad program oversight.

Reduce Improper Claims Payments with True Cost Avoidance

Improper claims payments has been recognized each year by the GAO as a significant factor in Medicaid waste and mismanagement. Improper payments cost the program billions of dollars every year, threatening the program's solvency and sustainability. One way Medicaid administrators could minimize improper payments immediately is to adopt technology solutions that help identify primary commercial payers in order to avoid making claims payments in error.

Health plans have difficulty determining primary coverage on pharmacy and medical claims because the data they access is not current, available, complete, or accurate. Thus, plans have no choice but to pay claims in error and chase reimbursement once other health insurance (OHI) is found. Unfortunately, for Medicaid plans, the actual monies recouped remain around twenty cents on the dollar.

Syrtis Solutions recognized that Medicaid plans needed a way to determine active OHI coverage to adjudicate claims properly. ProTPL, introduced in 2010, is a real-time point of sale cost avoidance service for government funded healthcare programs that delivers powerful, accurate, and actionable eligibility data. The solution gives health plans the ability to cost avoid Rx and medical claims and the associated costs of recovery.

Medicaid has remained on the GAO's High-Risk List since 2003. Throughout the years, the program has struggled with fiscal oversight and integrity. Medicaid's improper payment rate alone is costing billions of dollars each year. To remain solvent, Medicaid must improve its fiscal oversight of program expenditures and ensure that program resources are spent properly. At the moment, the best place to start saving resources and reducing improper payments is to provide Medicaid payers access to clean and actionable eligibility data that they can rely on.

Find out more. 

FY 2021 MEDICAID IMPROPER PAYMENTS

 

Medicaid has been designated a high-risk program by the Government Accountability Office (GAO) since 2003 because of improper payments, low-quality data, and administrative challenges. Earlier in November, the Department of Health and Human Services (DHHS) posted its Agency Financial Report. In FY 2021 Medicaid's estimated improper payments amounted to a staggering $98.72 billion. According to DHHS, the vast majority of these improper payments were a result of inadequate documentation and eligibility errors.

Just recently, CMS published the following Improper Payments Fact Sheet.

What You Need to Know:

• Improper payments represent payments that do not meet program requirements.
• The vast majority of improper payments occur in regards to people who may be eligible for care, but for whom there was an unintentional payment error or a reviewer can not determine if a payment was proper due to insufficient payment documentation from a state or a provider.
• Improper payments do not necessarily represent expenditures that should not have occurred and can include both overpayments and underpayments situations where there is insufficient documentation to determine if a payment is proper in accordance with program payment requirements.
• While fraud and abuse are improper payments, they are not synonymous; it is important to note that most improper payments are not attributable to fraud, and improper payment estimates are not fraud rate estimates.

Improper Payment Measurements:

Medicare

• CMS developed the Comprehensive Error Rate Testing (CERT) program to estimate the Medicare Fee-For-Service (FFS) program's improper payment rate.

• The CERT program cites improper payments in accordance with payment policies on any claim: 1) that was paid when it should have been denied or paid at another amount (including both overpayments and underpayments); and/or 2) for which documentation was insufficient to be an improper payment.

• The CERT program reviews a statistically valid stratified random sample of Medicare FFS claims to determine if they were paid properly under Medicare coverage, coding, and billing rules. If these criteria are not met, the claim is counted as either a total or partial improper payment.

• The majority of Medicare FFS improper payments fall into two categories:

• (1) insufficient documentation; and
• (2) the documentation provided for the items or services billed did not sufficiently demonstrate medical necessity.

Medicaid

• CMS estimates Medicaid and CHIP improper payments using the Payment Error Rate Measurement (PERM) program.

• The PERM program uses a 3-year, 17 state rotation, meaning each state is reviewed once every three years and each cycle measurement includes one-third of all states. The most recent three cycles (2021, 2020, and 2019) combined to form each year's overall national rate.
• PERM ensures a statistically valid random sample representative of all Medicaid and CHIP payments matched with federal funds meets a national precision requirement where CMS is 95% confident that the Medicaid and CHIP improper payment rates are within +/- 3 percentage points.
• The Medicaid and CHIP improper payment national rates are based on reviews of the FFS, managed care, and eligibility components of a State's Medicaid and CHIP program in the year under review.
• In addition, the PERM program combines individual state component estimates to calculate the national component estimates. National component rates and the Medicaid and CHIP rates are weighted by state size, such that a state with a $10 billion program is weighted more in the national rate than a state with a $1 billion program. A correction factor in the methodology ensures that each Medicaid improper payment is counted only once in the combined national rate.

• Medicaid and CHIP improper payment data released by CMS are based on reviews of whether states are implementing their Medicaid and CHIP programs in accordance with federal and state payment and eligibility policies.

Click here to read the white paper Improper Payments - Medicaid's Billion Dollar Problem

Improper Payments Do Not Necessarily Indicate Fraud:

• Improper payment rates are not measures of fraud in CMS programs. Most improper payments are caused by improper or inadequate documentation.
• Improper payments do not necessarily represent expenditures that should not have occurred.

• For example, a majority of improper payments are due to instances where information required for payment was missing, documentation that an eligibility determination was made correctly was missing from the state system, states did not follow the appropriate process for enrolling providers, and/or states did not follow the appropriate process for determining beneficiary eligibility. However, these improper payments do not necessarily represent payments to illegitimate providers or on behalf of ineligible beneficiaries. Had the missing information been on the claim and/or had the state complied with the enrollment or redetermination requirements, then the claims may have been payable. A smaller proportion of improper payments are instances where the State Agency had sufficient documentation to determine that payments should not have been made or should have been made in different amounts, which are considered monetary losses to the Federal Government (e.g., medical necessity, incorrect coding, and other errors).

• Improper payments can result from a variety of circumstances, including:

• 1) services with no documentation,
• 2) services with insufficient documentation, or
• 3) no record of the required verification of an individual's eligibility, such as income, specifically for Medicaid and CHIP.

• Proper payments occur when there is sufficient documentation to support payment in accordance with the program payment requirements. Two examples of proper payments include:

• Payments where the state appropriately maintained documentation of an eligibility verification requirement and appropriately determined eligibility based on program eligibility and payment requirements.
• Payments where sufficient documentation was provided to support medical necessity in accordance with program payment requirements.

Improper Payment Reporting Criteria

• The Payment Integrity Information Act of 2019 defines significant improper payments are defined as either:

• (i) improper payments greater than $10 million and over 1.5 percent of all payments made under that program, or.
• (ii) improper payments greater than $100 million.

• The Office of Management and Budget (OMB) has identified Medicare Fee-For-Service (FFS), Medicare Part C, Medicare Part D, Medicaid, and the Children's Health Insurance Program as susceptible to significant improper payments. The Advanced Premium Tax Credit program has also been identified as susceptible to significant improper payments. In FY 2021, CMS completed the development of the Federally-facilitated Exchange improper payment measurement and commenced measurement activities for future reporting.

CMS/State Collaboration on Improper Payments

• CMS collaborates with states in many ways to share information and help to ensure they maintain the proper documentation to demonstrate that payments are being made correctly. Examples include:.
• Medicaid Eligibility Quality Control (MEQC) Program: Under MEQC, states design and conduct pilots to evaluate the processes that determine an individual's eligibility for Medicaid and CHIP benefits. States have flexibility in designing pilots to focus on vulnerable or error-prone areas as identified by the PERM program and state. The MEQC program also reviews eligibility determinations that are not reviewed under the PERM program, such as denials and terminations.
• Enhanced State PERM Corrective Action Plan Process: CMS works with states to coordinate state development of corrective action plans to address each error and deficiency identified during the PERM cycle. After each state submits the corrective action plan, CMS monitors each state's progress in implementing effective corrective actions. Throughout the process, CMS also provides training opportunities to ensure compliance with federal policies.
• State Medicaid Provider Screening and Enrollment Data and Tools: CMS shares Medicare data to assist states with meeting Medicaid screening and enrollment requirements.
• Enhanced Assistance on State Medicaid Provider Screening and Enrollment: CMS provides ongoing guidance, education, and outreach to states on federal requirements for Medicaid provider screening and enrollment. CMS also assesses provider screening and enrollment compliance, provides technical assistance, and offers states the opportunity to leverage Medicare screening and enrollment activities.
• Medicaid Integrity Institute (MII): CMS offers training, technical assistance, and support to state Medicaid program integrity officials through the MII. More information is located at the Medicaid Integrity Institute website.

Click this link to learn more. 

ADMINISTRATIVE CHALLENGES IN THE MEDICAID PROGRAM

Medicaid has been designated as a high-risk government program by the GAO since 2003. The Medicaid program has struggled over the last seventeen years because of insufficient fiscal oversight and other administrative difficulties. These challenges will be exasperated as the program expands and enrollment climbs in the course of the COVID-19 pandemic. If Medicaid is expected to deliver on its goal to serve the health and wellness needs of our nation's most vulnerable low-income individuals and families, it is essential that these administrative problems be addressed.

In a recent report from the GAO, the agency analyzed federal Medicaid policies, state perspectives on challenges they encounter due to present policies, and what federal actions may be taken to resolve these problems. After speaking with Medicaid officials from 50 states and Washington D.C., the GAO was able to determine federal policies, laws, and regulations that caused difficulty to effectively administer the Medicaid program.

Four problematic areas cited by officials include coverage exclusions and care coordination, covered benefits and eligibility, Medicare and Medicaid alignment, and payment methods. In addition, administrative officials brought up reporting requirements and the inadequate guidance. There is also much consternation due to the lengthy delays when states are seeking approval to waive various statutory Medicaid requirements. CMS is already in the process of resolving these problematic areas and has released revised guidance, streamlined the waiver procedure, and is working with stakeholders to develop an updated reporting system.

Additionally, the GAO also found five relevant considerations that broadly apply to the reported areas of concern. They include targeting federal oversight to important areas, making use of program data, balancing oversight and flexibility for waivers and demonstrations, clarifying CMS policy, and responding to change.

IMPORTANT GAO CONSIDERATIONS

Targeting Federal Oversight To Crucial Areas

The GAO determined that program oversight tasks must support beneficiary accessibility to benefits and the proper use of federal expenditures to protect against improper payments. This consideration was based on the GAO's March report that estimated improper payments in the Medicaid program increased $21 billion in FY 2019. HHS stated that the surge was a result of inadequate documentation for eligibility determinations. Additionally, many improper payments resulted from noncompliance in screening and enrollment requirements.

Leveraging Program Data

Poor quality data has been another issue for Medicaid plans in recent times. Incomplete and outdated data make program oversight extremely problematic. The report stated that "accurate and complete data on key measures-- such as measures for beneficiary access and use of services and the costs of providing such services-- are critical for oversight, including ensuring proper payments, and for informing any evaluation of policies." Dependable quality data could help display the cost-effectiveness of expanding Medicaid coverage to other services. States and stakeholders agree that quality data will considerably aid in managing the Medicaid program.

Medicaid has been on the GAO's High-Risk List since 2003 due to poor oversight and other administrative issues. Over the last seventeen years, Medicaid officials have struggled to administer Medicaid due to laws, policies, and regulations. If the program is to become fiscally solvent while properly coordinating care, improving fiscal oversight and accessing quality data is essential.

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MEDICAID IMPROPER PAYMENTS IN 2019

Improper payments in the Medicaid program are payments full or partial claims payments paid in error or payments made to the incorrect party. Improper payments have been a major issue for Medicaid over the last few years and have cost the program's valuable resources. Across all federal programs, improper payments have been determined to total almost $1.7 trillion between 2003 and 2019. In March of this year, the Government Accountability Office (GAO) published its latest report, GAO-20-344, which estimated improper payments in federal agencies for FY 2019. The report indicates that federal agencies estimated improper payments amounted to a shocking $175 billion in 2019. The majority of the improper payments came from three programs: Medicaid, Medicare, and the Earned Income Tax Credit (EITC). Medicaid had a 14.9% improper payment rate, up nearly 5.1% from 2018, and represented 32.8% or $57.4 billion of the $175 billion in government improper payments. Unfortunately, understanding these payments and their impact continues to be a difficulty due to incomplete, unreliable, and understated estimates from government agencies. In addition, agencies are not complying with reporting and additional requirements from the Improper Payments Elimination and Recovery Act of 2010 (IPERA). For example, eight out of fourteen agencies failed to publish and meet targets for reducing improper payments in 2019.

From 2018 to 2019, Medicaid's improper payment rate increased by 5.1%. 

According to the Department of Health and Human Services (HHS), the five-point jump in payments made in error was due in part to the department's reintegration of the Payment Error Rate Measurement (PERM). In the prior four years, HHS did not estimate improper payments associated with eligibility and they also used a proxy estimate that was last reported in 2014. In addition, HHS was only able to estimate eligibility determination related improper payments for 17 states since the majority have not been measured since PERM was reintegrated. In the HHS FY 2019 agency financial report, the department cited that many of Medicaid's improper payments stemmed from states not complying with provider screening and enrollment requirements. Furthermore, eligibility errors identified by PERM were a result of insufficient documentation to confirm eligibility or noncompliance with the requirements for redetermining eligibility.

Improper payments are taking valuable resources away from the Medicaid program and other federal programs. These payments are reported as a monetary loss and they could have possibly been prevented or recovered. While reporting improper payments is helpful in understanding how prevalent they are, it does nothing to reduce them. This must be resolved, particularly in a time where unemployment has skyrocketed due to the Coronavirus pandemic. Millions of Americans are turning to the Medicaid program and every dollar counts.

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MEDICAID THIRD PARTY LIABILITY REVIEW FROM THE GAO

Identifying third party liability continues to be a challenge within the coordination of benefits for Medicaid. By law, plans are payers of last resort so whenever beneficiaries have other active coverage (OHI), those third parties should pay first. Presently, plans are required to incorporate new payment procedures to aid in ensuring that they do not pay more than they should. Despite the requirement, CMS is unsure as to whether or not plans have implemented the new procedures and the GAO is advising that the agency determines compliance.

The new payment procedures were enacted as part of The Bipartisan Budget Act of 2018. Before the legislation, Medicaid plans would regularly pay providers for services and then look for reimbursement from any liable third parties. This retrospective approach is known as Pay and Chase. Additionally, the law included a provision for the GAO to evaluate the potential impact of the legislation.

In August, the GAO released their report which included their discoveries and recommendations. They found that nine of the states reviewed are in various stages of implementing the law's third party liability changes. These changes affect whether providers must seek payment from a liable third party before the Medicaid plan pays for services. The new procedures apply to prenatal care services, pediatric preventive services, and services for children subject to child support enforcement. The report went on to point out:

"Officials from four of the nine selected states reported having fully implemented the changes for prenatal care services, which were required to be implemented starting in February 2018. Officials from the remaining five states were discussing the changes internally, researching how to implement the changes in their Medicaid payment systems, or waiting for additional guidance from the Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for overseeing states' Medicaid programs."

"None of the nine states had implemented the changes to pediatric preventive services and services for CSE beneficiaries, which must be implemented starting in October 2019. Officials from six states told GAO that they were in the early stages of exploring how they would make the changes, while the remaining three states had not developed such plans."

The GAO also found issues with the guidance that CMS issued to states for implementation of the third party liability changes. CMS's guidance incorrectly informs plans that providers are not required to seek payments from OHI before plans pay for some prenatal services.

The report also reveals that CMS is not adhering to its oversight responsibilities. It specifies that the agency has not effectively determined whether plans are complying with the updated third party liability requirements. CMS expects plans to comply, yet it does not verify that the changes have been implemented unless informed of non-compliance.

The GAO also discussed the impact of the changes with Medicaid specialists and stakeholders. According to the stakeholders, the new requirements could possibly result in a reduction in beneficiary access to care because providers would be less willing to see Medicaid patients. The two primary reasons are:

1. "The changes may increase administrative requirements for providers by requiring them to identify sources of coverage, obtain insurance information, and submit claims to third-party insurers before submitting them to Medicaid."
2. "The changes may result in providers waiting longer to receive Medicaid payment for certain services to the extent that states require providers to seek third-party payments before paying the providers' claims."

Lastly, the GAO report featured two recommendations to CMS. One of which was to ensure that the agency's guidance on third party liability requirements reflects current law and the other was to figure out the extent to which plans are complying with third party liability requirements.

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MEDICAID COSTS PUT EMPHASIS ON RECOVERY EFFORTS AND COST AVOIDANCE

In 1965, Title XIX of the Social Security Act established the Medicaid program to provide health care coverage to low-income individuals. Over time it has developed into one of the nation's largest payers for health care, covering one out of five Americans. In FY 2017, the jointly funded program made up 9.5% of federal spending. Because of Medicaid expansion and climbing health care costs, the program has become an even greater component of state budgets. To ensure that the program meets its goals and objectives, legislatures and plan administrators are working to improve program integrity by resolving its vulnerabilities.

COB Challenges

There are presently 56 unique Medicaid programs and each state is responsible for administering its program while remaining compliant to federal guidelines. These broad requirements give states the flexibility to determine covered populations, services, delivery models, and methods of payment. Additionally, states can also test and implement approaches outside of federal standards by obtaining Section 1115 waivers.

While the ability to tailor individual programs helps states meet their individual needs, problems emerge in the Coordination of Benefits (COB) and Third Party Liability (TPL), which is "the legal obligation of third parties to pay part, or all of the expenditures for medical assistance furnished under a Medicaid state plan."

Factors including the complexity of COB and TPL, the continuous flux of the Medicaid population, and uncoordinated eligibility data between federal and state systems leave the Medicaid program vulnerable to improper payments.

Medicaid Expansion Creates Added Complexity

Medicaid expansion has experienced intense debate after the Affordable Care Act revised Medicaid eligibility in 2010. Two years later, the Supreme Court ruled expansion optional and since then 37 states have chosen to expand their eligibility requirements. While more individuals are eligible for coverage, the increased population size has also added to the complexity of the program and emphasized the need for improved program integrity and recovery processes. Existing vulnerabilities, such as improper payments, must be resolved with effective cost avoidance solutions to help ensure the program's sustainability.

$36.2 Billion In Improper Payments

A High-Risk Issue from the Government Accountability Office (GAO) reported, "Medicaid covered about 75 million people in fiscal year 2018, at an estimated cost of $629 billion--$ 393 billion of which was paid by the federal government. CMS has projected that Medicaid spending will grow at an average rate of 5.7 percent per year from fiscal years 2017 through 2026. In fact, Medicaid spending is expected to reach $1 trillion by fiscal year 2026."

The GAO estimated that improper payments represented 9.8 percent ($36.2 billion) of Medicaid spending in 2018.

Medicaid has been on the GAO's high-risk list since 2003 due to the lack of federal oversight, it's size, and the complexity of the program. As health care costs increase and program eligibility expands, it is becoming a significant expenditure for the federal government and state budgets. Plan administrators need to implement cost avoidance technology solutions in order to save their plans money.

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LEGISLATION FAILS TO LOWER IMPROPER PAYMENTS IN GOVERNMENT-FUNDED PROGRAMS

Legislation like the Improper Payments Information Act (IPIA P.L. 107-300) and Executive Order 13520 looked to address improper payments in government-funded programs. IPIA ordered federal agencies to report on the number of improper payments occurring and lay out what measures are being taken to lower them. Order 13520 worked to pinpoint high-priority programs and increase transparency. Agencies were required to submit projected reduction estimates and specifics on how they would work to obtain them. Despite these pieces of legislation, government-funded programs continue to lose billions of dollars due to payments made in error.

According to the GAO, federal entities estimated about $141 billion in improper payments in 2017. The Congressional Research Service (CRS) also reported and discovered that the 20 high-priority programs identified as a result of Order 13520, accounted for 96% of the $141 billion. In the years ahead, the CRS anticipates that these programs will account for 90% of all improper payments.

STATUTE COMPLIANCE ISSUES

In their improper payment reporting, the GAO has regularly brought up the following four compliance issues:

• Federal entities struggle to collect accurate eligibility data.

• Agencies do not have reliable methods for identifying improper payments.

• Entities fail to steer resources towards compliance efforts mandated by law.

• Agencies go through the motions and see the compliance measures as a way to keep oversight at bay.

Surprisingly, while agencies struggle to comply with statues to report on improper payments, none of them require that agencies decrease payments made in error. Consequently, improper payment rates continue to rise and agencies engage in costly measures to report.

The CRS report specified, "nearly half of the high-priority programs have shown no improvement. Specifically, the error rates for seven programs have increased since they first began reporting data, and the error rate for one program has remained unchanged. Moreover, while the error rates for twelve programs have decreased, the decline has been less than 10% for five programs. In some cases, program error rates have not improved."

IMPROPER PAYMENTS LOWERED WITH QUALITY DATA

To reduce improper payments, the federal government will need to make a focused effort in targeting the root causes for these payments within high priority programs while at the same time implementing technology solutions.

CMS is one agency in particular that successfully implemented existing initiatives and innovative processes, such as its Fraud Prevention System, to deal with improper payments within its programs. Following the compliance efforts established in the Improper Payments Elimination and Recovery Act of 2010 (H.R. 3393), last year CMS reported its lowest improper payment rate in eight years.

The agency's Fraud Prevention System is an IT solution that takes advantage of data analytics to detect when mistakes or intentional behavior may result in improper payments or indicate fraud. CMS says that the system will yield a 20% savings increase.

According to the agency, "CMS employs multi-faceted efforts to target the root causes of improper payments, with an emphasis on prevention-oriented activities. Actions to prevent and reduce improper payments include: policy clarifications and simplifications; prior authorization initiatives that ensure applicable coverage, payment, and coding rules are met before services are rendered; a targeted probe and educate medical review strategy that focuses on outlier providers, limits the number of medical records requested, and puts emphasis on education and assistance in correcting claims errors; and provider education on Medicare policy."

Legislation has helped to bring the problem of improper payments into focus for agencies and government officials. Having said that, the statues directed by legislation are costly and primarily revolve around compliance and reporting as opposed to reducing improper payments. In order to stop improper payment rates from rising further, agencies need to look to innovate quality data solutions to identify and prevent fraud, waste, and abuse.

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GAO CRITICIZES MEDI-CAL'S OUT-OF-DATE REPORTING MODEL AND IMPROVED MEDICAID OVERSIGHT

In August, the GAO issued a report to Congress that focused on what CMS would need in order to better target risks and improve Medicaid oversight. The review discovered that one of the critical problems the agency is facing is the failure to incorporate new reporting technology. Currently, California's Medicaid program is still using paper files to report expenses and that translates into thousands of documents.

Carolyn Yocom is the Health Care Director at the GAO that focuses on Medicaid. She stated, "For this type of reporting on expenditures, California really should be able to provide that electronically."

Medi-Cal provides services to 1 in 3 Californians with a combined federal and state budget of $104 billion annually. Presently, the state utilizes 92 separate computer systems to run the program. However, according to DHCS, "Given system limitations and the magnitude of the supporting documentation, providing it electronically is currently not feasible."

Over the course of the program's lifespan, Medi-Cal has been unsuccessful in implementing new technology. For example, in 2010 Xerox acquired a contract worth $1.7 billion to create a new system for the program. However, the deal was terminated after six years of delay and according to the state, Xerox paid more than $123 million as a settlement deal. Conduent was then spun off into a separate company from Xerox to continue running the system and process claims.

The issue is even more problematic when you take into consideration that California's outdated paper reporting system is not only a problem within the state but its also entrenched across the country's healthcare system.

States are mandated to send Medicaid data to the federal government on a quarterly basis. This data consists of expenses and supporting documentation including invoices, cost reports, and eligibility records. Even though California provides its spending reports electronically, its supporting documentation is not.

Recently, California has made some attempts to upgrade its systems that would result in improved Medicaid oversight. DXC Technology was granted a contract in August to take over some of the functions of Conduent. In addition, program officials are also planning for a new system that would cost an estimated $500 million. If approved, the federal government would be accountable for 90% of the design and implementation costs and the state would cover $50 million out of pocket.

As the state begins updating its operations, a remedy to the program's reporting issues remains a focus among government officials. According to Elaine Howle, a state auditor, Medicaid's information technologies system, "needs to be replaced, because it is more than 40 years old, its operations are inefficient, maintaining the system is difficult and there is a high risk of system failure."

Howle wrote a letter to Governor Brown and other officials in June. She stated that California is paying roughly $30 million a year to maintain the 40-year old system.

The GAO also criticized CMS for its lack of Medicaid oversight. The report disagreed with the fact that the agency appoints nearly the same amount of staff to review case files regardless of the size of a state's program. As an example, under the ACA, California had ten times the amount of new enrollees as Arkansas. For that reason, California is at higher risk of enrollment errors and improper payments due to its program's size. Regardless of the substantial difference in enrollment figures, both states were assigned 30 staff members to review claims. In addition, the authors of the report specified that California represents 15% of federal Medicaid spending, while Arkansas only represents 1%.

Carolyn Yocom commented that CMS "needs to step back and assess where are the biggest threats and vulnerabilities." She also stated, "If you aren't looking, you don't know what you aren't catching."

According to the GAO, from FY2014 to FY2018 federal Medicaid spending rose to around 31% and at the same time, CMS financial oversight decreased by about 19%.

In a July letter to the GAO, DHHS agreed with the report's Medicaid oversight recommendations and wrote that it "will complete a comprehensive national review to assess the risk of Medicaid expenditures reported by states and allocate resources based on risk."

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GOVERNMENT OFFICIALS AND AGENCIES LOOK INTO MEDICAID'S INTEGRITY

In 2017, improper payments within the Medicaid program reached a total of $37 billion according to CMS. That amounts to 10 percent of the federal dollars spent on the program. Furthermore, 99.2 percent of the payments made are overpayments.To make matters worse, under the current legislation, national health spending is predicted to reach $5.7 trillion by 2026. When considering the rising costs of healthcare and the programs growth from expansion under the Affordable Care Act, government officials are concerned over the programs sustainability.

In an effort to address Medicaid fraud and overpayments, the Senate Homeland Security and Governmental Affairs Committee held a hearing in June. Those present to investigate the problems and solutions were Chairman Senator Ron Johnson (R) WI, Senator Clair McCaskill (D) MO, Comptroller General of the United States Government Accountability Office, Eugene L. Dodaro, and the U.S. Department of Health and Human Services Assistant Inspector General for Audit Services, Brian P. Ritchie. Over the course of the hearing, the ranking members and witnesses discussed the rising costs associated with the Medicaid program and what efforts should be made so that federal funds are spent efficiently and effectively.

GAO Recommendations

Comptroller General Dodaro represented the GAO at the hearing and suggested actions to mitigate improper payments and program integrity risks. He indicated that Medicaid's unique state-by-state structures combined with the size of the program are two elements that make overseeing the program difficult.

The GAO identified improper payments, supplemental payments, and demonstrations as three areas of risk within Medicaid that are estimated to exceed $900 billion by 2025. In order to strengthen oversight and address risk, the GAO recommended the following:

Improve Data
"The Centers for Medicare & Medicaid Services (CMS), which oversees Medicaid, needs to make sustained efforts to ensure Medicaid data are timely, complete, and comparable from all states, and useful for program oversight. Data are also needed for oversight of supplemental payments and ensuring that demonstrations are meeting their stated goals."

Target Fraud
"CMS needs to conduct a fraud risk assessment for Medicaid, and design and implement a risk-based antifraud strategy for the program."

Collaborate
"There is a need for a collaborative approach to Medicaid oversight. State auditors have conducted evaluations that identified significant improper payments and outlined deficiencies in Medicaid processes that require resolution."

Click here to see the GAO's full report.

DHHS Recommendations

Inspector General for Audit Services, Brian P. Ritchie represented DHHS and also weighed-in on the obstacles facing Medicaid. The Inspector General identified high improper payments rates, inadequate program integrity safeguards, and beneficiary health and safety concerns as risks that jeopardize the integrity of the program. Additionally, he testified that in order to preserve the program there needs to be more robust efforts made in regards to prevention, detection, and enforcement.

According to Ritchie, "CMS must do more to ensure that Medicaid payments are made to the right provider, for the right amount, for the right service, on behalf of the right beneficiary."

DHHS emphasized the importance of complete and reliable national Medicaid data for successful oversight and program management. They determined that the deficiency in quality data obstructs enforcement efforts. DHHS advised that CMS do the following:

"Ensure the completeness and reliability of data in the Transformed Medicaid Statistical Information System"

"Ensure that States report encounter data for all managed care entities"

"Reduce improper and wasteful payments and ensuring compliance with fiscal controls"

"Improve the oversight of Eligibility Determinations"

"Ensure that national Medicaid data are complete, accurate, and timely" 

"Facilitate State Medicaid agencies' efforts to screen new and existing providers by ensuring the accessibility and quality of Medicare's enrollment data"

Read through the department's complete list of recommendations here.

CMS's Efforts To Address Medicaid's Improper Payments, Waste, Fraud, and Abuse

Nearly a month after the meeting, the Senate Homeland Security and Governmental Affairs Committee conducted an additional hearing with the Administrator of The Centers for Medicare and Medicaid Services and the US Comptroller General. The hearing concentrated on examining CMS's efforts to protect against fraud and overpayments within Medicaid. The GAO expressed that while CMS has taken measures to address these threats, additional action is needed in order to strengthen the program's integrity.

CMS's Administrator, Seema Verma, testified at the hearing and presented CMS's efforts. She discussed the following:

• New audits of state beneficiary eligibility determinations
• Targeted audits of state managed care claims for federal match funds and rate setting
• Addressing the inherited backlog of disallowances
• Designated State Health Programs (DSHP) funding phase-out
• Intergovernmental transfers
• Budget neutrality policies for 1115 Medicaid demonstration projects

Furthermore, Administrator Verma promoted the optimization of data. She also pointed out it's significance in protecting the integrity of the program

According to CMS, "Improving Medicaid and CHIP data and systems is a high priority. Through strong data and systems, CMS and States can drive toward better health outcomes and improve program integrity, performance, and financial management in Medicaid and CHIP."

CMS is working to strengthen the Medicaid program's integrity by employing advanced analytics and technologies for the collection of health services data. In June, each of the 50 states, including Washington D.C. and Puerto Rico, began sending data from their programs to the Transformed - Medicaid Statistical Information System (T-MSIS). The system is designed to keep track of key information such as: enhanced information about beneficiary eligibility, beneficiary and provider enrollment, service utilization, claims and managed care data, and expenditure data for Medicaid and CHIP. Moving forward, the agency will be in charge of determining the quality and completeness of the data submitted.

Click here to read Administrator Verma's full statement.

The Medicaid program is one of the nation's largest sources of funding for medical and health-related services. As a result of concerns over the program's fiscal oversight and it's substantial amount of improper payments, Medicaid has been on the GAO's "High Risk List" since 2003. As the program continues to expand, government officials and federal agencies are working to address issues rooted in waste, fraud, and abuse.

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