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This brief evaluates what is currently known about fraud and abuse in the Affordable Care Act (ACA) Marketplace, including how the final Marketplace Integrity and Affordability Rule and the recently enacted budget reconciliation law change existing Marketplace enrollment and eligibility standards.
As Congress considers ways to help pay for extending tax cuts, some lawmakers have suggested that hundreds of billions of dollars in federal savings could be achieved by addressing fraud, waste and abuse in the Medicaid program. Three experts joined Health Wonk Shop series moderator Larry Levitt in an hour-long discussion designed to unpack claims about fraud and abuse and put them in a larger context.
This brief explains fraud, waste, abuse, and improper payments in Medicare and describes actions to ensure Medicare program integrity.
Program integrity efforts work to prevent and detect fraud, waste, and abuse, to increase program transparency and accountability, and to recover improperly used funds. This brief explains what is known about improper payments and fraud and abuse in Medicaid and describes ongoing state and federal actions to address program integrity.
Medicare Advantage plans denied 3.4 million prior authorization requests for health care services in whole or in part in 2022, or 7.4% of the 46.2 million requests submitted on behalf of enrollees that year, according to a new KFF analysis of federal data. That was a higher share of denials than in recent years.
Medicaid is a large source of spending in both state and federal budgets, making program integrity efforts important to prevent waste, fraud, and abuse and ensure appropriate use of taxpayer dollars. This brief explains what program integrity is, recent efforts at the Centers for Medicare and Medicaid Services (CMS) to address program integrity, and current and emerging issues.
Medicaid covers more than 60 million Americans and accounts for about one in six dollars spent on health care in the United States.
Headlines regularly call attention to pockets of fraudulent activity in the health care arena - scams that amount to millions and potentially billions of dollars. The stories typically focus on catching the crooks but not so much on efforts to prevent fraud, waste and abuse in health care programs. Both types of efforts are important.
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