CMS Orders 50 States to Tighten Medicaid Provider Reviews Over $100 Billion Fraud Risk
Updated
Updated · Fox News · May 15
CMS Orders 50 States to Tighten Medicaid Provider Reviews Over $100 Billion Fraud Risk
5 articles · Updated · Fox News · May 15
Dr. Mehmet Oz on April 21 gave states 30 days to tell CMS how they will strengthen Medicaid provider reviews, targeting what the administration says may be about $100 billion in fraudulent billing each year.
State revalidation checks are legally required at least every five years, but examples cited in the report show major gaps: Georgia had about 21,000 overdue providers, while more than 25% of Illinois' 222,000 providers had gone past the deadline.
Those reviews can catch expired licenses, dead or excluded providers, and cross-state billing by terminated operators; an inspector general report found 12% of providers terminated for cause in one state were active in another months later.
CMS and federal investigators point to recent cases including 447 Los Angeles hospices targeted for fraudulent billing and April's Operation Never Say Die, which charged multiple people in a $60 million phantom hospice scheme.
The administration argues tighter screening could replicate earlier Medicare savings: revalidating 1.6 million providers in the 2010s deactivated more than 500,000, revoked 34,000, and saved taxpayers $2.4 billion.
Could aggressive new fraud controls in Medicaid and Medicare inadvertently disrupt care for legitimate providers and patients?
With billions at stake, what safeguards are in place to ensure states' rapid provider revalidation doesn't create new vulnerabilities or errors?
How might digital identity verification and AI reshape the future of healthcare fraud prevention—and what risks come with rapid adoption?