Sneak Preview: GAO Urges CMS To Incorporate Antifraud Framework

December 29, 2017 | By Jerry Ashworth | Post a Comment

xsass_bookshot(The following was excerpted from a recent article in the Single Audit Information Service.) The Department of Health and Human Services (HHS) Centers for Medicare and Medicaid Services (CMS) plans to use information gleaned from its current fraud risk assessments of state-run health insurance marketplaces to help it conduct similar fraud risk assessments within the Medicaid and Medicare programs, in response to a recent recommendation from the Government Accountability Office (GAO).

GAO has designated Medicare and Medicaid as “high risk” federal programs partly due to their vulnerability to fraud, waste and abuse. Improper payment estimates for these programs totaled about $95 billion in federal fiscal year (FY) 2016.

CMS’ efforts to combat fraud in four key programs — Medicare, Medicaid, Children’s Health Insurance Program and the health insurance marketplace program — are part of a broader program-integrity approach to limit fraud, waste and abuse. Through this approach, CMS aims to address providers that have made unintentional errors, as well as those that have conducted more-serious instances of fraud or abuse. It then aims to target its corrective actions to fit the severity of the problem.

In a recent report, GAO determined that CMS spent about $1.45 billion in FY 2016 to combat fraud, waste and abuse in the Medicare and Medicaid programs. Among the steps the agency has taken to address these concerns include creating the Healthcare Fraud Prevention Partnership (HFPP) to share information with public and private stakeholders and to conduct studies related to health care fraud, waste and abuse. As of October 2017, CMS said the HFPP consisted of 89 public and private partners, including Medicare- and Medicaid-related federal and state agencies, law enforcement agencies, private health-insurance plans and antifraud and other health-care organizations. CMS also has relationships with law-enforcement partners, such as a collaboration with the Department of Justice’s (DOJ) Health Care Fraud unit, in which DOJ will share the names of providers committing fraud so that CMS can suspend them on the heels of the enforcement efforts.

However, GAO said that CMS could benefit by more fully aligning its efforts with the four components of GAO’s A Framework for Managing Fraud Risks in Federal Programs (also known as the Fraud Risk Framework). This framework provides a comprehensive set of key components and leading practices that agency managers can use when developing efforts to combat fraud in a strategic, risk-based manner. The components are: committing to combating fraud through an organized structure that minimizes fraud risk; assessing risks on a regular basis; designing and implementing strategies for specific risk-control activities; and evaluating outcomes of risk assessments and adjusting oversight if necessary.

(The full version of this story has now been made available to all for a limited time on Thompson’s Grants Compliance Expert site.)

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