E&C Committee holds hearing on Medicare and Medicaid fraud

On March 17, the House Energy and Commerce Subcommittee on Oversight and Investigations held a hearing titled, “Protecting Patients and Safeguarding Taxpayer Dollars: The Role of CMS in Combatting Medicare and Medicaid Fraud.” During the hearing, members agreed that fraud in federal health care programs is a serious problem but diverged on whether current oversight efforts are politically motivated.

The Centers for Medicare & Medicaid Services (CMS) testified about agency efforts to curb fraud, including shifting away from a “pay-and-chase” model towards front-end fraud prevention using new machine learning algorithms to flag suspicious claims. CMS also highlighted its Comprehensive Regulation for Uncovering Suspicious Healthcare (CRUSH) Request for Information (RFI) to inform future rulemaking.

The Cigna Group submitted RFI comments on March 30 supporting increased collaboration with CMS and strengthening coordination between programs to stop fraudulent actors from shifting between programs. We recommend that CMS pilot efforts first with high-risk sectors and geographic hotspots. We also raise concerns about fraudulent provider upcoding, fraudulent activity in the No Surprises Act Independent Dispute Resolution process, and broker oversight in the federal Marketplace.