Four of the six major programs run by the Centers for Medicare and Medicaid Services saw their improper payment rate increase in fiscal 2025.
Medicare Part C, Medicare Part D and Medicaid all saw upticks in how much money went out the door that shouldn’t have.
While not all improper payments are considered fraud, CMS is planning an all-out effort to reign in fraud specifically and improper payments more broadly.
CMS says it’s taking on this systemic challenge through both technology and regulatory reforms.
On the regulatory side, CMS released a request for information on Feb. 27 asking for feedback from the public on “potential regulatory changes that might be included in a potential future proposed rule, as well as other programmatic changes that could be implemented to make CMS more effective in crushing fraud to protect taxpayer dollars and the Americans we serve.”
CMS laid out…
This category refers to crimes committed by employees or insiders against their own organizations. It is often the most damaging because the perpetrator has authorized access to systems.
- Asset Misappropriation: The most common form, involving the theft of company resources. This ranges from simple “skimming” (taking cash before it’s recorded) to complex schemes involving the theft of inventory or intellectual property.
- Payroll Fraud: Employees may create “ghost employees” on the system, falsify their own timesheets to claim unworked overtime, or divert salary payments to their own accounts.
- Financial Statement Fraud: Management deliberately misrepresents the company’s financial health by inflating revenue or hiding liabilities to attract investors or meet performance bonuses.