Congressmen Brett Guthrie and John Joyce announced a hearing to examine fraud in Medicare and Medicaid. The session, titled “Common Schemes, Real Harm: Examining Fraud in Medicare and Medicaid,” aimed to address the misuse of taxpayer dollars and its impact on beneficiaries. “The goal of this hearing was to understand current trends in fraud schemes targeting Medicare and Medicaid nationwide—how taxpayer dollars were being wasted, how beneficiaries were affected, and how transnational crime organizations were increasingly involved—and to explore ways to better prevent and detect fraud,” said Chairmen Guthrie and Joyce.
Jessica Gay from Integrity Advantage Solutions LLC testified at the hearing. She emphasized that healthcare fraud, waste, and abuse (FWA) accounted for a significant portion of healthcare spending, with estimates ranging from 3% to 10%. In 2024, U.S. healthcare spending reached $5.3 trillion, accounting for about 18% of GDP.
Gay noted that FWA affected patients, taxpayers, and honest providers. Fraud led to unnecessary medical services that posed risks to patients’ health while draining financial resources. According to the Center on Budget and Policy Priorities, taxpayers contributed $1.7 trillion to federal health programs such as Medicare and Medicaid.
Specific areas of concern included Applied Behavioral Analysis services for children with autism spectrum disorder; Non-Emergency Medical Transportation services intended for medical appointments but often misused; Home and Community Based Services designed for long-term care outside institutions; laboratory services such as genetic testing that were not always necessary or practitioner-ordered; skin substitutes used without medical necessity; and durable medical equipment billed but not supplied.
Challenges identified included inadequate policy frameworks across states; under-resourced program integrity units; fragmented oversight between states and Managed Care Organizations (MCOs); insufficient emphasis on balancing people, process, and technology in program integrity efforts; and value quantification that focused more on financial recoupment than prevention.
Effectively combating these issues required strengthening policy frameworks at the state level, with federal defaults where policies were weak or nonexistent; improving education and awareness among investigators, auditors, analysts, and leadership regarding national schemes; enhancing interagency and cross-organization collaboration through data sharing, joint investigations, and coordinated communication; conducting comprehensive assessments to identify imbalances in people, processes, and technologies; and modernizing credentialing and oversight systems to enhance verification, ongoing monitoring, real-time alerts, and data integration by consolidating National Provider Identifier data, sanctions, billing histories, and other identifiers into accessible central platforms to streamline reporting and improve analysis.
For more information about the hearing, readers were directed to energycommerce.house.gov or to contact Annabelle Huffman at Annabelle.Huffman@mail.house.gov or Katie West at Katie.West@mail.house.gov.
