E&C Releases Staff Report Exposing How Fraudsters are Ripping Off Medicare and Medicaid and How More Must be Done to Protect These Programs
WASHINGTON, D.C. – Today, the House Committee on Energy and Commerce, chaired by Congressman Brett Guthrie (KY-02), through the work of the Energy and Commerce Subcommittee on Oversight and Investigations, chaired by Congressman John Joyce, M.D. (PA-13), released a Majority Staff Report detailing how fraud has continued to undermine the integrity of critical taxpayer-funded health care programs. The report also details the disparities in the oversight and enforcement of fraud within state Medicaid programs. The report outlines 13 investigative findings and 37 recommendations to strengthen program integrity and keep fraudsters out of Medicare and Medicaid.
“Every dollar stolen from Medicare and Medicaid is a dollar taken from the seniors, children, pregnant women, and Americans with disabilities these programs were created to serve,” said Chairman Guthrie. “That’s why Chairman Joyce and our Committee have made rooting out fraud a top priority. Our findings expose the worst actors, but the accompanying recommendations also lay out commonsense steps to help CMS and the states stop fraud before it happens. We will keep fighting to hold criminals accountable, protect patients, and safeguard taxpayer dollars.”
“The Oversight and Investigations Subcommittee is focused on rooting out fraud that threatens the future of Medicare and Medicaid. These crimes hurt patients and steal from the American taxpayer,” said Chairman Joyce. “We will continue to expose those who exploit the system, hold fraudsters accountable, and advance commonsense recommendations that states can implement. This cannot be solved alone. Protecting the integrity of these programs must be a shared goal, because millions of Americans are counting on us to get it right.”
Read the full report here.
BACKGROUND:
During the investigation, the Committee sent 12 letters, held three Oversight and Investigations hearings, and reviewed more than 100,000 pages of documents.
Key findings include:
- Medicare and Medicaid fraud is occurring nationwide.
- Some states do not consider fraud trends when setting required Medicaid provider risk levels, and they do not regularly update the risk levels that they set. This alleviates states from conducting more rigorous oversight that they would be required to conduct if the provider was assigned a higher risk level. These actions weaken a key safeguard that can help keep fraudsters out of these programs.
- States are not using audit and investigative authorities to their fullest potential to prevent Medicaid fraud from occurring. States vary in auditing capacity and are generally not focusing on high-risk providers in their state.
- Medicare and Medicaid have traditionally relied on the “pay and chase” model instead of stopping fraud before it happens. New efforts by CMS under the Trump Administration are investing in “detect and prevent” strategies to shut down fraudsters before they are paid.
Fraud puts vulnerable patients at risk. A 2019 Johns Hopkins study found that providers kicked out of Medicare for fraud and abuse were more likely to have been treating low-income seniors or people with disabilities. These patients may be unable to report inadequate care, which in some cases led to hospitalizations and deaths.
The Trump Administration is already working to address these issues. Since January 2025, it has uncovered $96.4 billion of fraud in HHS programs, stopped $46.2 billion from wrongly going out the door, and recovered $33.1 billion.