Uh-Oh The GOA Data Breakdown Finds Healthcare Fraud and Abuse

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The Government of Accountability Office, GAO, aka the “congressional watchdog,” investigates how the federal government spends taxpayer dollars. The GAO found four states had significantly abused government dollar through the involvment in unlawful activities such as Medicaid beneficiaries and providers receiving fraudulent payments. Arizona, Florida, Michigan and New Jersey combined, totaled to about 9.2 million beneficiaries and accounted for 13 percent of all Medicaid payments in the 2011 fiscal year. The fiscal year of 2011 was the most recent year where reliable data was available.


People are Double Dipping into Reimbursement Pools:

  • “About 8,600 beneficiaries had payments on their behalf concurrently by two or more GAO’s selected states (Arizona, Florida, Michigan and New Jersey) totaling at least $18.3 million.”
  • Under federal regulations, beneficiaries are not to have payments made on their behalf by two or more states concurrently. If a receiver obtains services in a different state his or her resident state should pay for the services.

The Government is Paying Medicaid Benefits to Deceased People:

  • “We identified approximately 200 deceased individuals in the four states who appear to have received Medicaid benefits.”
  • $9.6 million worth of benefits. The 200 deceased beneficiaries received these Medicaid benefits subsequent to their death. These payments are another implication of potential fraudulent activities.

The Government is Paying Medicaid Dollars to Excluded Providers:

  • “About 50 providers were excluded from federal health-care programs, including Medicaid, for a variety of reasons that include patient abuse or neglect fraud, theft, bribery or tax evasion.”
  • The states paid the claims of about $60,000. Excluded providers are placed on the following OIG exclusion lists, which organizations along with state Medicaid official must check no less than monthly: the List of Excluded Individuals and Entities (LEIE) and/or the System for Award Management (SAM).  The GOA found that 16 providers from the four states were incarcerated in state prisons at some point during the fiscal year 2011.

Providers with Suspended or Revoked Medical Licenses:

  • “All physicians applying to participate in state Medicaid programs must hold a current, active license in each state in which they practice.”
  • The states are then required to go through license verification steps to confirm the license has not expired and that there are no current limitations on the license.
  • “Additionally, states are required to provide CMS with information and access to certain information respecting sanctions taken against health-care practitioners and providers by their own licensing authorities.”
  • The GOA used data from the Federation of State Medical Boards (FSMB) and found that about 90 medical providers in the four states had their licenses revoked or suspended in the state they were receiving payment from during the fiscal year 2011 costing Medicaid at least $2.8 million.

How can this Happen and What Should be Done to Fix it?

  • “Since 2011, the Centers for Medicare & Medicaid Services (CMS) has taken regulatory steps to make the Medicaid enrollment process more rigorous and data-driven; however, gaps in beneficiary-eligibility verification guidance and data sharing continue to exist.”
  • The Medicaid program is a significant cost for the federal government and the states – it represents more than $310 billion in federal expenditures – therefore it is of the utmost importance the federal government and the states continue to find better way to prevent, and eliminate, this healthcare fraud and abuse of improper payments. 
  • “As part of this ongoing endeavor, increasing information and data-sharing efforts between the federal government and state Medicaid programs could help enhance efforts to identify improper payments and potentially fraudulent activities.”

What do YOU think should be done to prevent healthcare fraud? Start the conversation and comment below with your thoughts.

Written By: Michael Rosen – Co-Founder of ProviderTrust

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