Congress Takes Steps to Address Medicaid Fraud and Program Integrity

Congress has recently passed legislation aimed at improving the integrity of government health care programs, particularly in Medicaid and the Affordable Care Act (ACA) exchanges. This move comes in response to alarming reports highlighting potential fraud and inefficiencies in these systems.

The Centers for Medicare and Medicaid Services (CMS) released data indicating a significant rise in the percentage of enrollees in Bronze and heavily subsidized Silver plans who did not file any claims. In 2019, about 29% of Bronze plan enrollees and 23% of Silver plan enrollees had no claims. By last year, these figures had increased to 40%. This trend raises concerns about the effectiveness of enrollment processes, with critics suggesting that many individuals are being auto-enrolled into plans they do not utilize.

Chris Jacobs, founder and CEO of Juniper Research Group, commented on the implications of these findings. “The data suggests that a growing number of individuals are being enrolled in taxpayer-funded health coverage that they do not need or use,” he said. “This raises questions about the sustainability of such programs.”

The CMS data also indicated that states like Florida and Texas had the highest percentages of zero-claims enrollees, suggesting possible issues with income verification for those receiving subsidies. Critics argue that the current system incentivizes fraudulent claims, as individuals may misrepresent their income to qualify for “free” coverage.

In response to these findings, Congress has enacted measures to enhance program integrity. The recently passed reconciliation bill includes provisions to verify eligibility more rigorously, with enhanced subsidies set to expire on December 31, 2025. This expiration is expected to reduce the incentive for fraudulent enrollments significantly.

In a separate report, Louisiana’s legislative auditor revealed that the state’s Medicaid program had paid approximately $9.6 million for coverage of 1,072 beneficiaries after their date of death between February 2019 and March 2023. The report highlighted that insurers continued to receive payments for a median of 418 days after a beneficiary had died, with some cases extending to 799 days.

“Taxpayers deserve better oversight of how their dollars are spent,” said the Louisiana legislative auditor. “This report underscores the need for improved verification processes.”

The new legislation mandates that states check the Social Security Death Master File at least quarterly starting in 2027 to prevent payments to deceased individuals. Despite these measures, some experts remain skeptical about the potential savings, with the Congressional Budget Office estimating that the changes would save less than $500,000 annually nationwide.

Supporters of the legislation argue that these reforms are a necessary step toward ensuring that taxpayer funds are used appropriately. However, critics caution that without rigorous enforcement, the measures may not be sufficient to eliminate fraud entirely.

As Congress moves forward with these reforms, the focus remains on enhancing accountability within government health care programs. The recent reports serve as a reminder of the ongoing challenges in maintaining program integrity and protecting taxpayer interests.