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GAO Recommends CMS Realign Its Antifraud Efforts

The United States Government Accountability Office (GAO) has asked the Centers for Medicare and Medicaid Services (CMS) to improve its recognition and enforcement of antifraud, waste, and abuse efforts and to align with the GAO’s Fraud Risk Framework and the Fraud Reduction and Data Analytics Act of 2015.

While recognizing that CMS had established the Center for Program Integrity, an entity dedicated to antifraud efforts, the GAO took CMS to task for not conducting a fraud risk assessment of Medicare and Medicaid. The GAO stated, and CMS concurred, that a fraud risk assessment allows managers to fully consider fraud risks. “By developing a fraud risk assessment and using that assessment to create an antifraud strategy and evaluation approach, CMS could better ensure that it is addressing the full portfolio of risks and strategically targeting the most-significant fraud risks facing Medicare and Medicaid,” according to the report.

The GAO Framework from 2015 organized concepts and practices meant to aid federal program managers in detecting and managing fraud risk. The overall framework of the 2015 study asked managers to commit to combatting fraud by creating an organizational culture and structure conducive to fraud management, assess risks, design and implement a strategy to mitigate risks and evaluate and adapt to improve risk management. The GAO admitted that CMS had partially aligned itself with these goals, but had fallen short in several key areas.

The final GAO recommendations include the following:

  • CMS should require fraud awareness training for all new hires and all employees.
  • CMS should conduct fraud risk assessments for Medicare and Medicaid to include respective fraud risk profiles.
  • CMS should use the results of the fraud risk assessments to create, implement, and communicate an antifraud strategy that is aligned with regularly assessed fraud risks and include an approach for monitoring and evaluation.

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