Additional Actions Needed to Enhance Program Integrity and Save Billions

The Department of Health and Human Services estimated over $100 billion in improper payments in FY 2023 for Medicare and Medicaid, representing 43% of government-wide improper payments.

Improper payments in Medicare and Medicaid are significant, with estimates of improper payments in FY 2023 being over $51 billion for Medicare and over $50 billion for Medicaid.

CMS has taken steps to reduce improper payments, resulting in billions of dollars in savings, including automated fraud prevention and improved oversight of managed care.

Progress has been made in reducing improper payment rates, but substantial risks and unimplemented recommendations remain.

CMS's efforts include improved provider screening, prepayment claim reviews, and enhanced fraud prevention systems, but some recommendations, such as legislative authority for prepayment reviews, are still pending.

Seek legislative authority for prepayment claim reviews in Medicare.

Assess and optimize documentation requirements for both Medicare and Medicaid.

Improve collaboration with state auditors and use their findings to inform oversight.

Implement a comprehensive plan for provider revalidations post-COVID-19.

Expand provider screening and enrollment review, especially in Medicaid.