U.S. flag

An official website of the United States government, Department of Justice.

NCJRS Virtual Library

The Virtual Library houses over 235,000 criminal justice resources, including all known OJP works.
Click here to search the NCJRS Virtual Library

Health Care Fraud: Types of Providers Involved in Medicare Cases, and CMS Efforts to Reduce Fraud

NCJ Number
Kathleen M. King
Date Published
November 2012
15 pages
This testimony before the U.S. House Subcommittee on Health, Committee on Energy and Commerce, presented by Kathleen M. King of the U.S. Government Accountability Office (GAO), reports on GAO's work regarding health care fraud in Medicare and strategies that could help reduce such fraud.
Since 1990, GAO has designated Medicare as a high-risk program because its complexity and susceptibility to payment errors from various causes, added to its size, have made it vulnerable to fraud. Although there have been convictions for multimillion-dollar schemes that defrauded the Medicare program, the extent of the problem is not known, since there are no reliable estimates of the magnitude of fraud in the health-care industry. Common health care fraud schemes include providers or suppliers billing for services or supplies not provided or not medically necessary, purposely billing for a higher level of services than that provided, misreporting data to increase payment, paying kickbacks to providers for referring beneficiaries for specific services or to certain entities, or stealing providers' or beneficiaries' identities. The testimony focuses on the types of providers that have been investigated for fraud and the outcomes of those investigations, as well as strategies that could be used to combat Medicare fraud. The testimony indicates that medical facilities have been the most frequent subjects of criminal investigations, with hospitals being the most frequent subjects of civil investigations. The Center for Medicare and Medicaid Services (CMS) has made progress in implementing strategies for preventing fraud, and recent legislation provided it with enhanced authority; however, CMS has not implemented some of the key strategies GAO identified in it prior work in preventing fraud. These strategies are outlined. 2 tables