Congress Acts to Address Medicaid Fraud and Program Integrity

Congress has taken steps to enhance program integrity in government health care programs, particularly in Medicaid and the Affordable Care Act (ACA) exchanges. This action comes amid reports of significant fraud and misuse of taxpayer funds, including payments made for deceased beneficiaries.

Recent data from the Centers for Medicare and Medicaid Services (CMS) revealed troubling trends in the ACA exchanges. The percentage of enrollees in Bronze and heavily subsidized Silver plans without any claims increased from approximately 25% in 2019 to 40% in the last year. This rise suggests that many individuals may have been auto-enrolled in plans they did not want or need, leading to concerns about the integrity of the enrollment process.

Chris Jacobs, founder and CEO of Juniper Research Group, noted, “The data indicates a growing number of individuals are receiving taxpayer-funded health coverage without utilizing it, which raises questions about the effectiveness of current enrollment practices.”

The CMS data also highlighted that states like Florida and Texas had the highest percentages of zero-claims enrollees. Critics argue that this indicates potential fraud, with individuals possibly misrepresenting their income to qualify for “free” coverage. The enhanced subsidies that allow for such enrollments are set to expire on December 31, which may reduce incentives for fraudulent claims.

In a separate issue, a report from Louisiana’s legislative auditor revealed that the state’s Medicaid program paid at least $9.6 million to cover 1,072 beneficiaries after their deaths from February 2019 to March 2023. The report indicated that insurers continued to receive payments for a median of 418 days after a beneficiary’s death, with some payments extending for over two years.

“This situation is unacceptable. Taxpayers deserve better oversight of their funds,” said the Louisiana legislative auditor. The report highlighted ongoing issues with the state’s Medicaid program, which has previously faced scrutiny for similar problems in 2013 and 2017.

To address these issues, Congress included provisions in a recently passed reconciliation bill that will require states to check the Social Security Death Master File quarterly starting in 2027. This measure aims to prevent payments to deceased individuals and improve overall program integrity.

Despite these efforts, some lawmakers remain skeptical about the effectiveness of the proposed changes. The Congressional Budget Office estimated that the new measures would save less than $500,000 per year nationwide, raising questions about the anticipated impact of the reforms.

Jacobs expressed cautious optimism about the recent legislative actions, stating, “For once, things are finally looking up in this regard. However, ongoing vigilance is necessary to ensure taxpayer dollars are not misused.”

As Congress continues to grapple with issues of fraud and waste in government health care programs, the recent reports underscore the need for robust oversight and accountability. The upcoming changes may provide a framework for improved integrity, but the effectiveness of these measures remains to be seen.