HHS Cracks Down on $3.16B in Medicare Fraud with New Oversight Tools
The U.S. Department of Health and Human Services (HHS) has stepped up efforts to tackle improper payments in Medicare and Medicaid managed care. In 2023, its Office of Inspector General (OIG) recovered around $3.16 billion from fraudulent or incorrect claims. A new toolkit now targets high-risk diagnosis codes in Medicare Advantage to reduce wasteful spending even further.
In a recent testimony, Christi A. Grimm, the Inspector General of HHS, highlighted major weaknesses in Medicare Advantage (MA) risk adjustment. Nearly 70% of diagnosis codes submitted for payment lacked proper medical record support. Grimm proposed stricter rules to exclude diagnoses without clear evidence of healthcare services from risk adjustment calculations.
Medicaid managed care also faces ongoing issues. Errors in eligibility checks, duplicate payments for enrollees registered across multiple states, and funds disbursed for deceased individuals have drained resources. These problems persist despite existing safeguards.
To address the challenges, the OIG released a specialised toolkit in 2023. Designed to help insurers and regulators spot suspicious diagnosis codes, it aims to cut down on improper payments. Grimm stressed the need for stronger oversight and enforcement to prevent fraud, waste, and abuse in federal healthcare programmes.
The OIGâs latest measures come as part of a broader push to improve accountability in Medicare and Medicaid. With billions already recovered, the new toolkit and proposed reforms seek to tighten controls on risk adjustment and eligibility. The focus remains on reducing financial losses while ensuring payments align with actual patient care.
