HEALTH CARE FRAUD

Types of Providers Involved 

in Medicare Cases, and CMS 

Efforts to Reduce Fraud

Statement of Kathleen M. King 

Director, Health Care

Testimony 

Before the Subcommittee on Health, 

Committee on Energy and Commerce, 

House of Representatives

For Release on Delivery 

Expected at 10:00 a.m. EST

Wednesday, November 28, 2012

GAO-13-213T

United States Government Accountability Office

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Page 1 GAO-13-213T

Chairman Pitts, Ranking Member Pallone, and Members of the 

Subcommittee:

I am pleased to be here today to discuss our work regarding health care 

fraud in Medicare and to discuss strategies that could help reduce fraud. 

Since 1990, GAO has designated Medicare as a high-risk program, as its 

complexity and susceptibility to payment errors from various causes, 

added to its size, have made it vulnerable to fraud.1

Since 1997, Congress has provided funds specifically for activities to 

address fraud, as well as waste and abuse, in Medicare and other federal 

health care programs. In fiscal year 2011, the federal government 

allocated at least $608 million in funding to investigate and prosecute 

Although there have 

been convictions for multimillion dollar schemes that defrauded the 

Medicare program, the extent of the problem is unknown as there are no 

reliable estimates of the magnitude of fraud in the health care industry. 

Fraud is difficult to detect because those involved are engaged in 

intentional deception. According to the Department of Health and Human 

Services’ Office of Inspector General (HHS-OIG), common health care 

fraud schemes include providers or suppliers billing for services or 

supplies not provided or not medically necessary, purposely billing for a 

higher level of service than that provided, misreporting data to increase 

payments, paying kickbacks to providers for referring beneficiaries for 

specific services or to certain entities, or stealing providers’ or 

beneficiaries’ identities.

 

1

In 1990, we began to report on government operations that we identified as “high risk” for 

serious weaknesses in areas that involve substantial resources and provide critical 

services to the public. Medicaid is among those programs we have identified as high-risk 

and Medicare has been included since 1990. See GAO, High-Risk Series: An Update, 

GAO-11-278 (Washington, D.C.: February 2011). See also 

http://www.gao.gov/highrisk/risks/insurance/medicare_program.php. Medicare is the 

federally financed health insurance program for persons age 65 or over, certain individuals 

with disabilities, and individuals with end-stage renal disease. Medicare Parts A and B are 

known as Medicare fee-for-service (FFS). Medicare Part A covers hospital and other 

inpatient stays. Medicare Part B is optional, and covers hospital outpatient, physician, and 

other services. Medicare beneficiaries have the option of obtaining coverage for Medicare 

services from private health plans that participate in Medicare Advantage—Medicare’s 

managed care program—also known as Part C. All Medicare beneficiaries may purchase 

coverage for outpatient prescription drugs under Part D, either as a stand-alone benefit or 

as part of a Medicare Advantage plan. Fraud involves an intentional act or representation 

to deceive with the knowledge that the action or representation could result in gain.

 
 

Page 2 GAO-13-213T

cases of alleged fraud in health care programs.2

My testimony today focuses on the types of providers that have been 

investigated for fraud and the outcomes of those investigations, and 

strategies that could be used to combat Medicare fraud. This statement is 

informed primarily by our September 2012 report on health care fraud and 

8 years of prior work on fraud, waste, and abuse in health care 

programs.

The Centers for 

Medicare and Medicaid Services (CMS)—an agency within HHS—

oversees Medicare, Medicaid, and the Children’s Health Insurance 

Program (CHIP). Along with its contractors, CMS works to reduce fraud. 

The HHS-OIG along with the Department of Justice (DOJ)—including its 

Criminal and Civil Divisions, the U.S. Attorney’s Offices (USAOs) 

throughout the country, and the Federal Bureau of Investigation (FBI)—

work together to investigate and prosecute cases of health care fraud.

3

These products were developed using a variety of methodologies, 

including analyses of fraud investigations and outcomes data obtained 

from federal agencies, review of public court records, examination of 

relevant policies and procedures, and interviews with agency officials.

A full list of the products that this testimony is based on is 

provided at the end of this statement.

4

 

2

See Department of Health and Human Services and Department of Justice, Health Care 

Fraud and Abuse Control Program Annual Report for Fiscal Year 2011: February 2012. 

The program, which is under the joint direction of the Attorney General and the Secretary 

of the Department of Health and Human Services (HHS) is designed to coordinate federal, 

state, and local law enforcement activities with respect to health care fraud and abuse. 

Additional funds to combat health care fraud spent by HHS and the Department of Justice 

(DOJ) are not included in this figure.

The work on which these products were based was conducted in 

accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provided a reasonable basis for our findings and 

conclusions based on our audit objectives.

3

See GAO, Health Care Fraud: Types of Providers Involved in Medicare, Medicaid, and 

the Children’s Health Insurance Program Cases; GAO-12-820 (Washington, D.C.: Sep. 7, 

2012).

4

The products listed at the end of this statement contain detailed information on the 

methodologies used in our work.
 

Page 3 GAO-13-213T

In recently completed work, we found that medical facilities (such as 

medical centers, clinics, and practices) and durable medical equipment 

suppliers were the most frequent subjects of criminal fraud cases in 

Medicare, Medicaid, and CHIP in 2010.5 Hospitals and medical facilities 

were the most frequent subjects of civil fraud cases, including cases that 

resulted in judgments or settlements.

According to 2010 data, about one-quarter of the 7,848 subjects 

investigated in criminal health care fraud cases were medical facilities or 

were affiliated with these facilities. Additionally, about 16 percent of 

subjects were durable medical equipment suppliers. Among the subjects 

investigated in criminal fraud cases, a small percentage (approximately 

3 percent) were individuals who were beneficiaries of health care 

programs.

Most of the subjects investigated for criminal fraud in 2010 were not 

pursued—meaning that the HHS-OIG did not refer the subject’s case to 

DOJ for prosecution. According to the 2010 data, 1,086 subjects were 

charged in criminal fraud cases and approximately 85 percent of them 

(925 subjects) were found guilty, pled guilty, or pled no contest to some or 

all of the criminal charges against them. Among those subjects that were 

found or pled guilty or no contest, the most frequent subjects were 

medical facilities (18.7 percent) or durable medical equipment suppliers 

(18.5 percent). See table 1 below for additional information on subjects 

who were found or pled guilty or no contest in 2010 criminal cases by 

provider type.

 

5

GAO-12-820. We use the term “subjects” to refer to individuals and entities involved in 

fraud cases. These subjects can be individuals, such as a dentist or a nurse; an 

organization, such as a pharmaceutical manufacturer; or a facility, such as a hospital.

Medical Facilities 

Were the Most 

Frequent Subjects of 

Criminal 

Investigations, and 

Hospitals Were the 

Most Frequent 

Subjects of Civil 

Investigations 

Medical Facilities and 

Durable Medical 

Equipment Suppliers Were 

the Most Frequent 

Subjects of Criminal Fraud 

Cases in 2010
 

Page 4 GAO-13-213T

Table 1: Number and Percentage of Criminal Health Care Fraud Subjects That Were 

Found or Pled Guilty or No Contest by Provider Type, 2010

Number of subjects 

that were found 

or pled guilty or 

no contest

Percentage of total 

number of subjects 

that were found 

or pled guilty or 

no contest

Medical facilities

Medical centers or clinicsa 130

18.7%

Medical practices 43

Durable medical equipment suppliers 171 18.5

Other centers, clinics, or facilities 58 6.3

Other 49 5.3

Home health agencies 42 4.5

Pharmacies 40 4.3

Management service providers 33 3.6

Nursing homes 14 1.5

Medical transportation companies 14 1.5

Pharmaceutical manufacturers or suppliers 9 1.0

Mental health centers, clinics, or facilities 9 1.0

Medical supply companies 8 0.9

Insurance companies 5 0.5

Dental clinics or practices 4 0.4

Government employees, contractors, or grantees 3 0.3

Hospitals 2 0.2

Unknown affiliation

Individualsa 220

Health care providers 52 31.6

Data unavailable 19

Total 925

Source: GAO analysis of Department of Health and Human Services’ Office of Inspector General (HHS-OIG) and Department of 

Justice’s (DOJ) U.S. Attorneys’ Offices (USAO) data.

Notes: Data in this table are for calendar year 2010. For the subjects in the DOJ’s USAO data, we 

identified the provider type using the court documents obtained from the Public Access to Court 

Electronic Records database. The data from HHS-OIG pertained only to health care fraud in 

Medicare, Medicaid, and the Children’s Health Insurance Program; however, data from the USAOs 

may have also included other health care fraud.

a

Among the 130 subjects affiliated with medical centers or clinics, 8 subjects were beneficiaries. 

Among the 220 individuals whose affiliation was unknown, 95 were beneficiaries. In total, there were 

103 beneficiaries who were found or pled guilty or no contest to some or all of the criminal charges 

against them. This represents approximately 11.1 percent of all criminal subjects who were found or 

pled guilty or no contest.
 

Page 5 GAO-13-213T

Additionally, about 11 percent of the subjects found guilty or who pled 

guilty or no contest were beneficiaries of health care programs. Among 

the 925 subjects that were found or pled guilty or no contest, 103 subjects 

were beneficiaries—95 of whom are listed as individuals in Table 1 and 8 

of whom were affiliated with medical centers or clinics. For example, in 

one of these criminal cases, a number of people associated with a 

medical clinic, including owners, an administrator, employees, a 

physician, and beneficiaries pled guilty or were convicted for their 

participation in a scheme to defraud Medicare. The fraud scheme 

involved recruiting beneficiaries through kickbacks for the purpose of 

submitting bills for injection and infusion treatments, which were not 

provided or not medically necessary.

Hospitals constituted nearly 20 percent of the 2,339 subjects of civil fraud 

cases investigated in 2010, and other medical facilities accounted for 

about 18 percent of the subjects. Less than 1 percent of subjects involved 

in civil health care fraud cases were beneficiaries of health care 

programs.

Not all of the subjects investigated in 2010 civil cases were pursued; by 

pursued, we mean that the USAO or DOJ’s Civil Division received the 

case and took some sort of action. Approximately 47 percent of subjects 

were involved in civil cases that were pursued and the remaining 

53 percent were involved in cases that were not pursued for a variety of 

reasons, including lack of resources or insufficient evidence as reported 

by the HHS-OIG. According to the 2010 data, 1,087 subjects were 

involved in civil fraud cases that were pursued, and among those, 602 

subjects were involved in cases that resulted in a judgment or settlement 

for the government or the relator.6

 

6

Individuals, known as relators, can bring civil health care fraud suits in the name of the 

government under the False Claims Act (FCA). The FCA prohibits certain actions, 

including the knowing presentation of a false claim for payment by the federal 

government. 31 U.S.C. § 3729(a)(1)(A). In these cases, known as qui tam cases, the 

relator can receive a portion of a monetary settlement, and reasonable expenses and 

attorneys’ fees and costs. 31 U.S.C. § 3730(b),(d).

Twenty-seven percent of the subjects 

in cases that were pursued were hospitals, and about 17 percent were 

medical facilities. None of those 602 subjects were beneficiaries of health 

care programs. See table 2 for additional information on provider types for 

Hospitals and Medical 

Facilities Were the Most 

Frequent Subjects of Civil 

Fraud Cases, Including 

Cases That Resulted in 

Judgments or Settlements
 

Page 6 GAO-13-213T

subjects where the case resulted in a settlement or judgment for the 

government or relator.

Table 2: Number and Percentage of Subjects in Civil Health Care Fraud Cases with 

Judgment for Government or Relator, Settlement, or Both by Provider Type, 2010

Number of subjects 

with judgment, 

settlement, or both

Percentage of total 

number of subjects 

with judgment,

settlement, or both

Hospitals 165 27.4%

Medical facilities

Medical practices 65

Medical centers or clinics 35 16.6

Other centers, clinics, or facilities 41 6.8

Home health agencies 34 5.6

Nursing homes 26 4.3

Durable medical equipment suppliers 25 4.2

Management service providers 21 3.5

Dental clinics or practices 21 3.5

Pharmaceutical manufacturers or suppliers 19 3.2

Insurance companies 15 2.5

Pharmacies 13 2.2

Medical transportation companies 11 1.8

Mental health centers, clinics, or facilities 5 0.8 

Other 5 0.8

Medical supply companies 3 0.5

Government employees, contractors, or grantees 2 0.3

Unknown affiliation

Data unavailable 58

Health care providers 34

Individuals 4 15.9

Total 602

Source: GAO analysis of Department of Health and Human Services Office of the Inspector General (HHS-OIG), Department of 

Justice’s U.S. Attorneys’ Offices (USAOs), and DOJ’s Civil Division data.

Notes: Data in this table are for calendar year 2010. For the subjects in the USAOs and DOJ’s Civil 

Division data, we identified the provider type using the court documents obtained from the Public 

Access to Court Electronic Records database. The data from HHS-OIG pertained only to health care 

fraud in Medicare, Medicaid, and the Children’s Health Insurance Program; however, data from the 

USAOs and DOJ’s Civil Division may also include other health care fraud.
 

Page 7 GAO-13-213T

CMS has made progress in implementing strategies to prevent fraud, and 

recent legislation provided it with enhanced authority. However, CMS has 

not implemented some of the key strategies we identified in our prior work 

to help CMS address challenges it faces in preventing fraud. Among 

others, these strategies include strengthening provider enrollment 

processes and standards, improving pre- and post-payment claims 

review, and developing a robust process for addressing identified 

vulnerabilities.

• Strengthening provider enrollment processes and standards—As 

we have reported in the past, strengthening the standards and 

procedures for provider enrollment could help reduce the risk of 

enrolling providers intent on defrauding Medicare.7 Although CMS has 

taken some important steps to identify and prevent fraud, including 

implementing provisions in Patient Protection and Affordable Care Act 

(PPACA), such as screening providers by risk level, more remains to 

be done to prevent making erroneous Medicare payments because of 

fraud.8 In particular, we have found CMS could do more to strengthen 

provider enrollment screening to avoid those intent on committing 

fraud, such as requiring a surety bond for certain types of at-risk 

providers and additional disclosure of information such as previous 

payment suspensions from other federal programs.

• Improving pre- and postpayment review of claims—As we have 

reported in the past, having robust controls in claims payment 

systems to prevent payment of problematic claims can help reduce 

loss.9

 

7

See GAO, Medicare Program Integrity: CMS Continues Efforts to Strengthen the 

Screening of Providers and Suppliers, 

Effective prepayment edits that deny claims for ineligible 

providers and suppliers depends on having timely and accurate 

information about them, such as whether the providers are currently 

enrolled and have the appropriate license or accreditation to provide 

specific services. In prior work, we found weaknesses in the database 

that maintains Medicare provider and supplier enrollment information 

related to the frequency with which CMS’s contractors update 

GAO-12-351, (Washington, D.C.: Apr. 10, 2012).

8

Pub. L. No. 111-148, 124 Stat.119 (2010), as amended by Health Care and Education 

Reconciliation Act of 2010 (HCERA), Pub. L. No. 111-152, 124 Stat. 1029, which we refer 

to collectively as PPACA.

9

See GAO, Medicare: Progress Made to Deter Fraud, but More Could Be Done, 

GAO-12-801T, (Washington, D.C.: June 8, 2012).

CMS Has Made 

Progress in 

Implementing 

Strategies to Prevent 

Fraud, but Further 

Actions are Needed
 

Page 8 GAO-13-213T

enrollment information and the timeliness and accuracy of 

information.10 Although CMS is working to improve the timeliness and 

accuracy of the provider and supplier information, it is too soon to tell 

if these efforts will better prevent payments to ineligible providers and 

suppliers. Additionally, further actions are needed to improve use of 

CMS technology systems that could help CMS and program integrity 

contractors identify fraud both before and after claims have been 

paid.11 For example, we recently examined CMS’s new predictive 

analytics system—the Fraud Prevention System—and found that 

although it has been implemented and is in use, it is not yet fully 

integrated with existing information technology systems. This level of 

integration would allow for the prevention of payments until suspect 

claims can be investigated and determined to be valid.12 To ensure 

that the implementation of the Fraud Prevention System is successful, 

we recommended to CMS that it define quantifiable benefits expected 

and mechanisms for measuring the results of using the system. In 

response to our report, HHS officials agreed with our recommendation 

and noted that CMS intends to establish outcome-based performance 

targets based on the first year of the system’s implementation.

• Developing a robust process for addressing identified 

vulnerabilities—As we have reported in the past, having 

mechanisms in place to resolve vulnerabilities that lead to improper 

payments is critical to effective program management and could help 

address fraud.13

 

10

For example, fraud in the Medicare program can be 

reduced by making it more difficult for thieves to steal beneficiaries’ 

Social Security numbers (SSN), which are printed on beneficiaries’ 

Medicare cards. In recent work, we found that CMS had not 

committed to a plan for removing SSNs from Medicare cards, and that 

CMS’s cost estimates for options it explored to remove SSNs were 

not well documented or reliable. We recommended that CMS select 

an approach for removing the SSN from the Medicare card that best 

GAO-12-351. 

11See GAO, Fraud Detection Systems: Centers for Medicare and Medicaid Services 

Needs to Ensure More Widespread Use, GAO-11-475 (Washington, D.C.: June 30, 2011).

12See GAO, Medicare Fraud Prevention: CMS Has Implemented a Predictive Analytics 

System, but Needs to Define Measures to Determine Its Effectiveness, GAO-13-104

(Washington, D.C.: Oct. 15, 2012).

13GAO-12-801T. 
 

Page 9 GAO-13-213T

protects beneficiaries from identity theft and minimizes burdens for 

providers, beneficiaries, and CMS; we also recommended that CMS 

develop an accurate, well-documented cost estimate for such an 

option using standard cost-estimating procedures.14 CMS agreed with 

our recommendation and indicated that it would take steps to revise 

its cost estimates on the basis of concerns we highlighted.

Although CMS has taken some important steps to identify and prevent 

fraud, including implementing provisions in PPACA, more remains to be 

done to prevent making erroneous Medicare payments because of fraud. 

It is critical that CMS implement and make full use of new authorities 

granted by recent legislation, as well as incorporate recommendations 

made by us, and the HHS-OIG in these areas. Moving from “pay and 

chase” to effective deterrence that prevents fraud from occurring in the 

first place is key to ensuring that federal funds are used efficiently and for 

their intended purposes.

As the authorities and requirements in recent legislation become part of 

Medicare’s operations, additional evaluation and oversight will be 

necessary to determine whether they are implemented as required and 

have the desired effect. We are investing significant resources in a body 

of work that assesses CMS efforts to refine and improve its fraud 

detection and prevention efforts. Notably, we are assessing the 

effectiveness of different types of prepayment edits in Medicare and of 

CMS’s oversight of its contractors in implementing those edits to help 

ensure that Medicare pays claims correctly the first time. Additionally, we 

have a study underway that is examining how federal agencies—such as 

CMS, HHS-OIG, and DOJ—are allocating funds received from the Health 

Care Fraud and Abuse Control Program to reduce fraud, as well as the 

effectiveness of such efforts. We are also examining a number of issues 

concerning CMS’s oversight and management of its Zone Program 

Integrity Contractors—the contractors responsible for detecting and 

investigating potential fraud—including how they prioritize their work and 

are evaluated by CMS. In addition, we are examining CMS’s oversight of 

some of the contractors that conduct reviews of claims after payment.

These studies are focused on additional actions for CMS that could help 

the agency more systematically reduce fraud in the Medicare program.

 

14See GAO, Medicare: CMS Needs an Approach and a Reliable Cost Estimate for 

Removing Social Security Numbers from Medicare Cards, GAO-12-831 (Washington, 

D.C.: Aug. 1, 2012). 
 

Page 10 GAO-13-213T

Because of the amount of program funding at risk, fraud will remain an 

inherent threat to Medicare, so continuing vigilance to reduce 

vulnerabilities will be necessary. Individuals intent on defrauding 

Medicare will continue to develop new approaches to try to circumvent 

program safeguards and investigative and enforcement efforts. Although 

targeting certain types of providers that CMS has identified as high risk 

may be useful, it may allow other types of providers committing fraud to 

go unnoticed. We will continue to assess efforts to fight fraud and provide 

recommendations to CMS, as appropriate, that we believe will assist the 

agency and its contractors in this important task. We urge CMS to 

continue its efforts as well.

Chairman Pitts, Ranking Member Pallone, and Members of the 

Subcommittee, this concludes my prepared statement. I would be happy 

to answer any questions you or other members of the subcommittee may 

have.

If you or your staff have any questions about this testimony, please 

contact me at (202) 512-7114 or kingk@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on 

the last page of this statement. Martin T. Gahart, Assistant Director; 

Christie Enders; and Drew Long were key contributors to this statement.
Related GAO Products

Page 11 GAO-13-213T

Medicare Fraud Prevention: CMS Has Implemented a Predictive 

Analytics System, but Needs to Define Measures to Determine Its 

Effectiveness. GAO-13-104. Washington, D.C.: October 15, 2012.

Health Care Fraud: Types of Providers Involved in Medicare, Medicaid, 

and the Children’s Health Insurance Program Cases. GAO-12-820. 

Washington, D.C.: September 7, 2012.

Medicare: CMS Needs an Approach and a Reliable Cost Estimate for 

Removing Social Security Numbers from Medicare Cards. GAO-12-831. 

Washington, D.C.: August 1, 2012.

Medicare: Progress Made to Deter Fraud, but More Could Be Done. 

GAO-12-801T. Washington, D.C.: June 8, 2012.

Medicare Program Integrity: CMS Continues Efforts to Strengthen the 

Screening of Providers and Suppliers. GAO-12-351. Washington, D.C.: 

April 10, 2012.

Improper Payments: Remaining Challenges and Strategies for 

Governmentwide Reduction Efforts. GAO-12-573T. Washington, D.C.: 

March 28, 2012.

2012 Annual Report: Opportunities to Reduce Duplication, Overlap and 

Fragmentation, Achieve Savings, and Enhance Revenue. 

GAO-12-342SP. Washington, D.C.: February 28, 2012.

Fraud Detection Systems: Centers for Medicare and Medicaid Services 

Needs to Expand Efforts to Support Program Integrity Initiatives. 

GAO-12-292T. Washington, D.C.: December 7, 2011.

Medicare Part D: Instances of Questionable Access to Prescription 

Drugs. GAO-12-104T. Washington, D.C.: October 4, 2011.

Medicare Part D: Instances of Questionable Access to Prescription 

Drugs. GAO-11-699. Washington, D.C.: September 6, 2011.

Medicare Integrity Program: CMS Used Increased Funding for New 

Activities but Could Improve Measurement of Program Effectiveness. 

GAO-11-592. Washington, D.C.: July 29, 2011.

Improper Payments: Reported Medicare Estimates and Key Remediation 

Strategies. GAO-11-842T. Washington, D.C.: July 28, 2011.

Related GAO Products
Related GAO Products

Page 12 GAO-13-213T

Fraud Detection Systems: Additional Actions Needed to Support Program 

Integrity Efforts at Centers for Medicare and Medicaid Services. 

GAO-11-822T. Washington, D.C.: July 12, 2011.

Fraud Detection Systems: Centers for Medicare and Medicaid Services 

Needs to Ensure More Widespread Use. GAO-11-475. Washington, D.C.: 

June 30, 2011.

High-Risk Series: An Update. GAO-11-278. Washington, D.C.: 

February 16, 2011.

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