Investigations of Medicare and Medicaid Fraud and Abuse--Improvements Needed

HRD-77-19: Published: May 23, 1977. Publicly Released: May 23, 1977.

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Investigations of the Department of Health, Education, and Welfare (HEW) into potential Medicare fraud and abuse cases, identified from Medicare contractors' internal control systems were reviewed. Also reviewed were Medicaid fraud and abuse investigations carried out by two states, Missouri and California.

Investigations of Medicare fraud and abuse were weak in that some complaints were prematurely closed and sampling procedures and monitoring of regional office and contractor investigations were inadequate. About half of the fraud cases have been prosecuted, usually successfully, but there was often delay or unwillingness to prosecute. The States are responsible for Medicaid investigations, and Federal action has been minimal. Limited reviews of two States' efforts showed wide variance in the investigations. Medicare and Medicaid investigations were not well coordinated. Recent organizational changes in HEW should provide better investigatory oversight.

Recommendation for Executive Action

  1. Status: Closed

    Comments: Please call 202/512-6100 for additional information.

    Recommendation: HEW should better monitor investigations so that they are not terminated prematurely; sample more effectively to detect fraudulent billing; reduce paperwork by referring complaints directly to contractors not to regional office; coordinate with the Department of Justice for timely decisions on prosecution; develop investigative priorities; hire personnel with necessary investigatory experience; delineate organizational responsibilities for investigations within HEW; coordinate between HEW and the States; help Missouri develop a more active investigation program; and stress with California officials the importance of criminal prosecutions.

    Agency Affected:

 

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