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.

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