WASHINGTON, D.C. — The Centers for Medicare & Medicaid Services said its Medicaid Fraud War Room helped stop more than $203 million in potentially improper payments during its first 88 days by coordinating federal and state action against 50 high-risk providers.
The initiative, launched April 23 with the White House Task Force to Eliminate Fraud, brings together CMS, the Department of Health and Human Services Office of Inspector General, state Medicaid agencies and federal law enforcement partners.
CMS said the providers were identified through data analytics used to detect suspicious billing patterns and generate investigative leads. The agency did not provide details about the providers, the alleged conduct or how much of the $203 million had already been paid.
The HHS inspector general issued 42 notices of intent to exclude providers from federal health care programs, covering about $160.7 million in Medicaid payments made since Jan. 1, according to CMS.
States took 15 enforcement actions following referrals from the fraud unit, representing about $46.2 million in Medicaid payments over the same period.
Seven providers faced both federal and state action. After accounting for that overlap, CMS said the actions involved 50 unique providers and approximately $203.3 million in Medicaid payments.
“Every dollar lost to Medicaid fraud is a dollar taken away from vulnerable Americans who rely on it,” CMS Administrator Dr. Mehmet Oz stated.
A notice of intent to exclude is not a final determination that fraud occurred. CMS characterized the providers as high-risk and the payments as potentially improper or subject to enforcement action.
The fraud unit is modeled on CMS’s Medicare Fraud Defense Operations Center and is intended to accelerate communication among federal investigators, state officials and Medicaid administrators.
“The Medicaid Fraud War Room is what modern program integrity looks like: federal and state partners working off the same data, in real time,” CMS Deputy Administrator and Chief Operating Officer Kim Brandt stated.
CMS said the operation will continue using analytics and coordinated referrals to identify providers for potential exclusion, payment restrictions or other enforcement measures.
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