Medicaid

Medicaid fraud schemes cross state lines and enforcement jurisdictions, engaging the different or competing priorities of federal, state, and local agencies in efforts to investigate, prosecute, and enforce program compliance. Essential components of an effective strategy with program integrity include coordinating the efforts of the multiple players, investing in preventive strategies, and dedicating adequate resources to fraud control units. The Health Care Financing Administration, the federal agency that runs Medicaid, established a fraud and abuse national initiative in 1997 to bring together groups at the state level to provide training, share information, and address common concerns. Despite HCFA's efforts to facilitate the states' activities, questions remain about its role as a steward of Medicaid funds.

GAO noted that: (1) GAO's body of work on health care fraud and abuse indicates that programs the size and structure of Medicaid are inherently vulnerable to exploitation; (2) fraud schemes often cross state lines and enforcement jurisdictions, entailing a number of federal, state, and local agencies that may have different or competing priorities in their efforts to investigate, prosecute, and enforce compliance; (3) experience shows that coordinating the efforts of the multiple players, investing in preventive strategies, and dedicating adequate resources to fraud control units are essential components of an effective program integrity strategy; and (4) GAO's work shows that the Health Care Financing Administration, the agency in the Department of Health and Human Services responsible for administering Medicaid federally, is in a position to work in partnership with the states to ensure an appropriate level of commitment in states' efforts to control Medicaid fraud and abuse.