CMS Orders Medicaid Audits in Data-Driven Fraud Crackdown

The Centers for Medicare and Medicaid Services is doubling down on data-driven oversight and technology-enabled verification to root out fraud in Medicaid, with new requirements pushing states to modernize how they track and validate providers.

In the next 30 days, all states will have to provide CMS with a plan on how they will “revalidate providers,” Administrator Mehmet Oz said during Politico’s Public Health Care Summit Tuesday. Oz, who didn’t indicate whether states would be given extra resources to conduct the reevaluations, said that all 50 states will be required to account for areas in their state at “high risk” for waste, fraud and abuse. 

“That means, if there are 5,000 people providing services — which was the number from one of the states that we’re looking at — and they can’t even get several 100 of those people to respond to the queries about who they are, do they really exist? What’s their social security number? Do they have a right to provide those services,” Oz said. “Isn’t that the basic thing you would want to do if you actually care about the program; make sure that legitimate providers are providing services that you’re paying for and doing it the right way?” 

Oz said that he didn’t anticipate the states’ audits eliminating or slowing down CMS’ essential programs or services. 

“I believe this audit and others like it will save the programs,” he said. “I want to make sure we have access to care for the people who actually need care.” 

Leaning on Tech and Data

This announcement appears to be the latest iteration of the Trump administration’s effort to combat alleged health care fraud. In February, CMS and the White House announced a “major crackdown” on Medicare and Medicaid fraud.

The administration’s “data-driven strategy” included “a nationwide moratorium on Medicare enrollment for certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers; and a nationwide call to action for Americans to support fraud prevention, including stakeholder input on how CMS can continue to expand and strengthen its efforts.” 

In addition to combatting fraud, Oz said his main priority at CMS is to recruit “high-quality individuals” to help restore confidence in the health care system and reassure people that health care can be high quality and affordable.  

“All those are achievable,” he said. “In part because we do have remarkable technological advances that are supporting and changing how we deliver medicine in America. We have a golden age of value and quality health care. It’s right at our fingertips. We get the right people in government to help turn on the levers so that we can unleash this opportunity.” 

Oz added that private-sector partnerships will also play a key part in advancing his goals for CMS, especially regarding scientific advancements.