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Report: Steps needed to better fight health care fraud

It's understood that the federal government is an enormous labyrinth that stretches into every corner of the nation. There are about two million federal employees (not counting members of the armed forces), so it is impossible for any one person or agency to watch over it all.

The Centers for Medicare & Medicaid Services has an enormous mission: administer those two huge programs, as well as the Children's Health Insurance Program and the Health Insurance Marketplace. On top of all of that, CMS is tasked with preventing fraud in the programs it oversees.

One of the problems for CMS is that isn't adequately budgeted to fight fraud in Medicare and Medicaid, said experts interviewed for a recent Bloomberg article. Private health insurers budget about three times as much CMS for administrative costs that include fraud prevention.

Plus, CMS struggles with inadequate fraud risk assessments, the sources told Bloomberg. Proper risk assessments would evaluate Medicare and Medicaid and identify areas at risk of fraud. The current approach is to allocate funds targeting identified fraud, but a comprehensive fraud risk assessment would enable CMS to diagnose fraud risks before they become problems for agencies and taxpayers.

It's not all bad news, a Bloomberg legal adviser says. "The creation of CPI [the Center for Program Integrity], the adoption of the fraud prevention system, and the implementation of the UPICs [Unified Program Integrity Contractors] show that CMS is doing a better job and continues to improve on the anti-fraud front."

If you or your firm is under investigation involving allegations of health care fraud, you can speak to an attorney experienced in vigorous, protective representation in these matters.

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