Congress Targets Medicaid Fraud with New Legislation

Congress has taken steps to address potential fraud in government health care programs, particularly in Medicaid and the Affordable Care Act (ACA) exchanges. New legislation aims to enhance program integrity and prevent improper payments, including those made to deceased individuals.

Recent data from the Centers for Medicare and Medicaid Services (CMS) revealed concerning trends in the ACA exchanges. The percentage of enrollees in Bronze and heavily subsidized Silver plans without any claims increased significantly, rising from approximately 25% in 2019 to 40% last year. This trend suggests that many individuals may have been auto-enrolled into plans they did not need or use.

“This data indicates a growing number of individuals receiving taxpayer-funded coverage without any actual medical claims,” said Chris Jacobs, founder and CEO of Juniper Research Group. “It raises questions about the integrity of the enrollment process.”

Critics argue that the Biden administration’s focus on expanding health coverage has led to inefficiencies and potential fraud. The CMS data also indicated that states like Florida and Texas had higher percentages of zero-claims enrollees, suggesting possible misrepresentation of income to qualify for subsidies.

In response to these findings, Congress passed a reconciliation bill that includes provisions to enhance verification processes for Medicaid and ACA enrollees. These changes are set to take effect by the end of 2023, with enhanced subsidies expiring on December 31, 2025, which may reduce incentives for fraudulent claims.

In a separate issue, a report from Louisiana’s legislative auditor highlighted significant payments made to deceased individuals under the state’s Medicaid program. From February 2019 to March 2023, Louisiana paid at least $9.6 million for Medicaid coverage to 1,072 beneficiaries after their deaths. Insurers continued to receive payments for an average of 418 days post-mortem due to inadequate reporting of beneficiaries’ deaths.

“This is a serious problem that has persisted over the years, and it underscores the need for better oversight,” said the Louisiana legislative auditor.

The new legislation mandates that states must check the Social Security Death Master File at least quarterly starting in 2027 to prevent payments to deceased individuals. However, some experts question the Congressional Budget Office’s estimate that this measure will save less than $500,000 annually nationwide.

Supporters of the new measures believe they will improve the integrity of Medicaid and ACA programs, ensuring that taxpayer dollars are used appropriately. However, critics remain skeptical about the effectiveness of these changes and the potential for ongoing fraud.

As Congress moves forward with these reforms, the focus will be on ensuring that both state and federal officials are held accountable for protecting taxpayer funds from misuse. The recent legislative actions represent a significant step toward addressing long-standing issues in government health care programs.