by John K. Iglehart in the New England Journal of MedicineMarshaling expanded financial resources, aggressive new legal authority, and rare bipartisan solidarity, the Obama administration is accelerating federal efforts to fight health care fraud, waste, and abuse that cost taxpayers and private insurers billions of dollars every year. Although the new forms of authority are granted by the Affordable Care Act (ACA), which Republicans unanimously opposed, most GOP legislators strongly support — and some even sponsored measures to enable1 — the more rigorous crackdown on illegal activities that plague Medicare, Medicaid, and private insurers. Under past policies, Congress and the executive branch “way, way, way” underspent on fighting health care fraud, according to Kerry Weems, who was acting administrator of the Centers for Medicare and Medicaid Services (CMS) from 2007 to 2009.2
Since 1990, the Government Accountability Office (GAO) has designated Medicare as a high-risk federal program because its vast size and complexity make it vulnerable to fraud, waste, and abuse. In 2009, government-wide “improper payments” totaled $98 billion — more than half of it paid by Medicare and Medicaid. It is uncertain how much of the activity that resulted in these payments was actual fraud, but Lewis Morris, chief counsel of the Office of Inspector General (OIG), Department of Health and Human Services (DHHS), told the Senate Finance Committee last year, “Although we cannot measure the full extent of health care fraud in Medicare and Medicaid, everywhere we look we continue to find fraud in these programs.” The National Health Care Antifraud Association, an organization of some 100 private insurers and public agencies, estimates conservatively that $60 billion of total national health care spending each year is accounted for by fraud.
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