**GAO-10-844T**                      Published: Jun 15, 2010. Publicly Released: Jun 15, 2010.                  

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## Highlights

GAO has designated Medicare as a high-risk program since 1990, in part because the program's size and complexity make it vulnerable to fraud, waste, and abuse. Fraud represents intentional acts of deception with knowledge that the action or representation could result in an inappropriate gain, while abuse represents actions inconsistent with acceptable business or medical practices. Waste, which includes inaccurate payments for services, also occurs in the Medicare program. Fraud, waste, and abuse all can lead to improper payments, overpayments and underpayments that should not have been made or that were made in an incorrect amount. In 2009, the Centers for Medicare & Medicaid Services (CMS)--the agency that administers Medicare--estimated billions of dollars in improper payments in the Medicare program. This statement, will focus on challenges facing CMS and selected key strategies that are particularly important to helping prevent fraud, waste, and abuse, and ultimately to reducing improper payments, including challenges that CMS continues to face. It is based on nine GAO products issued from September 2005 through March 2010 using a variety of methodologies, including analysis of claims, review of relevant policies and procedures, stakeholder interviews, and site visits. GAO received updated information from CMS in June 2010.

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## Topics

Auditing and Financial Management

BeneficiariesBilling proceduresClaimsClaims processingClaims settlementContractor violationsContractorsCriminal activitiesCriminal background checksErroneous paymentsFee-for-service plansHealth care programsHealth care servicesHealth resources utilizationInvestigations by federal agenciesManaged health careOverpaymentsProgram abusesUnderpaymentsWaste, fraud, and abuse