Congress Takes Action to Address Medicaid Fraud and Program Integrity

Congress has enacted new measures aimed at improving integrity within government healthcare programs, particularly focusing on Medicaid and the Affordable Care Act (ACA) exchanges. This follows reports indicating significant issues with fraud and improper payments in these systems.

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 who did not file any claims rose from approximately 25% in 2019 to 40% in 2023. This suggests that many individuals may have been auto-enrolled into plans they neither wanted nor used, raising concerns about the efficiency of taxpayer-funded health coverage.

Critics argue that this trend indicates a failure in oversight. “The data shows a growing number of individuals receiving benefits without any corresponding healthcare usage, which raises questions about the integrity of the enrollment process,” said Chris Jacobs, founder and CEO of Juniper Research Group.

In addition to the ACA issues, a report from Louisiana’s legislative auditor highlighted that the state’s Medicaid program paid at least $9.6 million to 1,072 beneficiaries after their deaths from February 2019 to March 2023. The report noted that insurers continued to receive payments for an average of 418 days post-mortem, with some cases extending beyond two years.

“This is not the first time we’ve seen these issues in Louisiana’s Medicaid program. The state needs to implement better checks to prevent such payments,” said the auditor, emphasizing the need for improved oversight.

The recently passed reconciliation bill includes provisions aimed at reducing these types of fraud. Starting in 2027, states will be required to check the Social Security Death Master File quarterly to ensure deceased individuals are not receiving Medicaid benefits. This measure is expected to enhance program integrity, although some skeptics question whether it will have a significant financial impact. The Congressional Budget Office estimated that this change would save less than $500,000 annually nationwide.

Supporters of the bill argue that it is a necessary step toward accountability. “Taxpayers deserve assurance that their money is not being misused. These reforms are a step in the right direction,” Jacobs stated.

As the Biden administration has prioritized expanding health coverage, critics contend that this focus has led to lax oversight and increased opportunities for fraud. The enhanced subsidies that allowed many individuals to qualify for zero-dollar coverage are set to expire on December 31, 2025, which may further reduce incentives for fraudulent claims.

The combination of these new measures and the expiration of enhanced subsidies could lead to significant changes in how Medicaid and ACA programs are administered. As Congress continues to address these issues, the focus remains on ensuring that taxpayer dollars are used effectively and responsibly.