CMS lambasted for failing to curb Medicaid, Medicare fraud and abuse

Lawmakers grilled a CMS administrator Tuesday as government watchdog groups released more damning reports on the federal agency's efforts at eliminating waste, fraud and abuse in Medicare and Medicaid.

Rep. Chris Collins (R-N.Y.) said the CMS is part of his weekly stump speech and “not in a complimentary way.” He said the agency's performance would not be tolerated in the private sector.

“If you worked for me, you'd be fired this afternoon,” he told Dr. Shantanu Agrawal, deputy administrator and director of the CMS' Center for Program Integrity.

HHS' Office of Inspector General released three reports Tuesday timed to a House Energy and Commerce Committee's Subcommittee on Oversight and Investigations hearing on combating improper payments and ineligible providers. In 2014, the government reported nearly $80 billion misspent on Medicare and Medicaid.

The OIG found that 37 states had not implemented fingerprint-based criminal background checks, and 11 were not performing site visits when enrolling providers in their Medicaid programs.

Ann Maxwell, assistant inspector general with the OIG's Office of Evaluation and Inspections, said her agency has found that the Medicare enrollment data system called the Provider Enrollment, Chain and Ownership System has historically been “incomplete, inconsistent and inadequate.” A recent review found that nearly all provider names from PECOS did not match the names filed with state Medicaid agencies. Also, many ownership names in PECOS did not match those collected directly from providers.

“It's hard to know who you're doing business with if you can't even get their names straight,” she said.

The OIG also found that the CMS does not have a comprehensive database for identifying providers that have been terminated for cause. Because of this, 12% of providers terminated for cause by a Medicaid agency in 2011 were still participating in another state's Medicaid program in January 2012.

Investigations by the Government Accountability Office found flaws in the software the CMS uses to verify providers addresses, leading to more than 26,000 providers with addresses not matching any on file with the U.S. Postal Service.

Agrawal said the CMS has implemented more than 100 GAO and IOG recommendations in the past year and is working with tools under the Affordable Care Act to improve address verification and improved enrollment processes. Maxwell and a GAO representative said they believed the CMS is working in good faith to implement their agencies' suggestions.

Agrawal said many of the questionable payments result from mistakenly incomplete documentation from providers, and the CMS must rely on states for verifying Medicaid information. The CMS is working with states to provide technical assistance.

“It's not a single solution, it's a multitude of solutions,” he said.