Medicaid Program Integrity: Expanded Federal Role Presents Challenges to and Opportunities for Assisting States
Published: 2011-12-07T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The Centers for Medicare & Medicaid Services (CMS), the federal agency that oversees Medicaid, estimated that improper payments in the federal-state Medicaid program were $21.9 billion in fiscal year 2011. The Deficit Reduction Act of 2005 established the Medicaid Integrity Program and gave CMS an expanded role in assisting and improving the effectiveness of state activities to ensure proper payments. Making effective use of this expanded role, however, requires that federal resources are targeted appropriately and do not duplicate state activities. GAO was asked to testify on Medicaid program integrity. GAO's statement focuses on how CMS's expanded role in ensuring Medicaid program integrity (1) poses a challenge because of overlapping state and federal activities regarding provider audits and (2) presents opportunities through oversight to enhance state program integrity efforts. To do this work, GAO reviewed CMS reports and documents on Medicaid program integrity as well as its own and others' reports on this topic. In particular, GAO reviewed CMS reports that documented the results of its state oversight and monitoring activities. GAO also interviewed CMS officials in the agency's Medicaid Integrity Group (MIG), which was established to implement the Medicaid Integrity Program. This work was conducted in November and December 2011. GAO discussed the facts in this statement with CMS officials.
section_title: What GAO Found
paragraphs: The key challenge faced by the Medicaid Integrity Group (MIG) is the need to avoid duplication of federal and state program integrity efforts, particularly in the area of auditing provider claims. In 2011, the MIG reported that it was redesigning its national provider audit program. Previously, its audit contractors were using incomplete claims data to identify overpayments. According to MIG data, overpayments identified by its audit contractors since fiscal year 2009 were not commensurate with its contractors' costs. The MIG's redesign will result in greater coordination with states on a variety of factors, including the data to be used. It remains to be seen, however, whether these changes will result in an increase in identified overpayments. The table below highlights the MIG's core oversight activities, which were implemented from fiscal years 2007 through 2009. The MIG's core oversight activities present an opportunity to enhance state efforts through the provision of technical assistance and the identification of training opportunities. The MIG's assessment of state program integrity efforts during triennial onsite reviews and annual assessments will need to address data inconsistencies identified during these two activities. Improved consistency will help ensure that the MIG is appropriately targeting its resources. The Medicaid Integrity Institute appears to address a state training need and create networking opportunities for program integrity staff.

section_title: Letter
paragraphs: I am pleased to be here today to discuss Medicaid program integrity, that  is, preventing improper payments that result from fraud, waste, and  abuse. Until the Deficit Reduction Act of 2005 (DRA) expanded the role  of the Centers for Medicare & Medicaid Services (CMS), the federal  agency that oversees Medicaid, Medicaid program integrity had been  primarily a state responsibility. CMS’s expanded role presents an  opportunity to assist and improve the effectiveness of state activities, but  also requires that federal resources are targeted appropriately and do not  duplicate state activities.
Medicaid is jointly funded by federal and state governments. It is one of  the largest social programs in the federal budget—covering about   67 million people in fiscal year 2010—and one of the largest components  of state budgets. In fiscal year 2010, Medicaid expenditures totaled about  $401 billion, with a federal share of $270 billion and a state share of   $132 billion. As a result of flexibility in the program’s design, Medicaid  consists of 56 distinct state-based programs. The challenges inherent in  overseeing a program of Medicaid’s size and diversity make the program  vulnerable to improper payments, which may be the result of fraud,  waste, and abuse. Because of the program’s risk of improper payments  as well as insufficient federal and state oversight, we added Medicaid to  our list of high-risk programs in January 2003. CMS estimated that  Medicaid improper payments were $21.9 billion for fiscal year 2011.
States are the first line of defense against Medicaid improper payments.  Specifically, they must comply with federal requirements to ensure the  qualifications of the providers who bill the program, detect improper  payments, recover overpayments, and refer suspected cases of fraud and  abuse to law enforcement authorities. At the federal level, CMS, an  agency within the Department of Health and Human Services (HHS), is  responsible for supporting and overseeing state Medicaid program  integrity activities.
In 2005, we testified that CMS needed to increase its commitment—both  the alignment of resources and strategic planning—to helping states fight  Medicaid fraud, waste and abuse. Subsequently, the DRA established  the Medicaid Integrity Program and included other provisions designed to  increase CMS’s support for state activities to address Medicaid fraud,  waste, and abuse. The DRA provided appropriations to implement the  Medicaid Integrity Program, and the Patient Protection and Affordable  Care Act (PPACA) enacted in March 2010 gave CMS and states  additional provider and program integrity oversight tools.
You asked GAO to testify today on Medicaid program integrity. My  remarks focus on how CMS’s expanded role in ensuring Medicaid  program integrity (1) poses a challenge because of overlapping state and  federal activities, particularly in the area of auditing provider claims; and   (2) presents opportunities through oversight to enhance state program  integrity efforts. To do this work, we reviewed CMS reports and  documents on Medicaid program integrity as well as our own and others’  reports on this topic. In particular, we reviewed CMS reports that  documented the results of its state oversight and monitoring activities. We  also interviewed CMS officials in the agency’s Medicaid Integrity Group,  which was established to implement the Medicaid Integrity Program. We  conducted our work in November and December 2011 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. The data presented in this statement were  obtained from CMS and we did not independently verify their reliability.  We believe that the evidence obtained provides a reasonable basis or our  findings and conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: CMS is responsible for overseeing Medicaid and state Medicaid agencies  are responsible for administering the program. Although each state is  subject to federal requirements, it develops its own Medicaid  administrative structure for carrying out the program including its  approach to program integrity. Within broad federal guidelines, each state  establishes eligibility standards and enrolls eligible individuals;  determines the type, amount, duration, and scope of covered services;  sets payment rates for covered services; establishes standards for  providers and managed care plans; and ensures that state and federal  funds are not spent improperly or diverted by fraudulent providers.  However, state Medicaid programs do not work in isolation on program  integrity; instead, there are a large number of federal agencies, other  state entities, and contractors with which states must coordinate.
subsections: section_title: State Medicaid Program Integrity Activities
paragraphs: Generally, each state’s Medicaid program integrity unit uses its own data  models, data warehouses, and approach to analysis. States often  augment their in-house capabilities by contracting with companies that  specialize in Medicaid claims and utilization reviews. However, as  program administrators, states have primary responsibility for conducting  program integrity activities that address provider enrollment, claims  review, and case referrals. Specifically, CMS expects states to  collect and verify basic information on providers, including whether the  providers meet state licensure requirements and are not prohibited  from participating in federal health care programs    maintain a mechanized claims processing and information system  known as the Medicaid Management Information System (MMIS).  MMIS can be used to make payments and to verify the accuracy of  claims, the correct use of payment codes, and a beneficiary’s  Medicaid eligibility.    operate a Surveillance and Utilization Review Subsystem (SURS) in  conjunction with the MMIS that is intended to develop statistical  profiles on services, providers, and beneficiaries in order to identify  potential improper payments. For example, SURS may apply  automatic post-payment screens to Medicaid claims in order to  identify aberrant billing patterns.  submit all processed Medicaid claims electronically to CMS’s Medical  Statistical Information System (MSIS). MSIS does not contain billing  information, such as the referring provider’s identification number or  beneficiary’s name, because it is a subset of the claims data  submitted by states. States provide data on a quarterly basis and  CMS uses the data to (1) analyze Medicaid program characteristics  and utilization for services covered by state Medicaid programs, and  (2) generate various public use reports on national Medicaid  populations and expenditures.  refer suspected overpayments or overutilization cases to other units in  the Medicaid agency for corrective action and refer potential fraud  cases to other appropriate entities for investigation and prosecution.
Our reports and testimonies from 2001 through 2006 identified gaps in  state program integrity activities and noted that the support provided by  CMS to states was hampered by resource constraints. For example, in  2004, we reported that 15 of 47 states responding to our questionnaire  did not affirm that they conducted data mining, defined as analysis of  large data sets to identify unusual utilization patterns, which might  indicate provider abuse.
section_title: Recent Legislation Has Conferred New Responsibilities on CMS and States
paragraphs: The DRA established the Medicaid Integrity Program to provide effective  federal support and assistance to states to combat fraud, waste, and  abuse. To implement the Medicaid Integrity Program, CMS created the  Medicaid Integrity Group (MIG), which is now located within the agency’s  Center for Program Integrity. The DRA also required CMS to hire  contractors to review and audit provider claims and to educate providers  on issues such as appropriate billing practices.
The Medicaid Recovery Audit Contractor (RAC) program was established  by PPACA. Each state must contract with a RAC, which is tasked with  identifying and recovering Medicaid overpayments and identifying  underpayments. Each state’s RAC is required to be operational by  January 1, 2012. Medicaid RACs will be paid on a contingency fee  basis—up to 12.5 percent—of any recovered overpayments and states  are required to establish incentive payments for the detection of  underpayments. Figure 1 identifies the key federal and state entities  responsible for Medicaid program integrity.
Fraud detection and investigations often require more specialized skills  than are required for the identification of improper payments because  investigators must establish that an individual or entity intended to falsify  a claim to achieve some gain. As a result, fraud is more difficult to prove  than improper payments and requires the involvement of entities that can  investigate and prosecute fraud cases. In 1977, Congress authorized  federal matching funds for the establishment of independent state  Medicaid Fraud Control Units (MFCU). MFCUs are responsible for  investigating and prosecuting Medicaid fraud. In general, they are located  in State Attorneys Generals’ offices. MFCUs can, in turn, refer some  cases to federal agencies that have longstanding responsibility for  combating fraud, waste, and abuse in Medicare and Medicaid—the  HHS’s Office of Inspector General (HHS-OIG), the Federal Bureau of  Investigation (FBI), and the Department of Justice.
section_title: CMS’s MIG Implemented Core Activities from 2006 through 2009 but Effective Coordination Is Needed Because of Overlap with Ongoing State Efforts
paragraphs: A key challenge CMS faces in implementing the statutorily required  federal Medicaid Integrity Program is ensuring effective coordination to  avoid duplicating state program integrity efforts. CMS established the MIG  in 2006 and it gradually hired staff and contractors to implement a set of  core activities, including the (1) review and audit of Medicaid provider  claims; (2) education of state program integrity officials and Medicaid  providers; and (3) oversight of state program integrity activities and  provision of assistance. Because states also routinely review and audit  provider claims, the MIG recognized that coordination was key to avoiding  duplication of effort. In 2011, the MIG reported that it was redesigning its  national provider audit program to allow for greater coordination with  states on data, policies, and audit measures. According to MIG data,  overpayments identified by its review and audit contractors over the first   3 years of the national audit program were not commensurate with the  contractors’ costs.
subsections: section_title: Core MIG Activities Were Implemented Gradually from 2006 to 2009
paragraphs: The DRA provided CMS with the resources to hire staff whose sole duties  are to assist states in protecting the integrity of the Medicaid program.  The MIG’s core activities were implemented gradually from fiscal year  2006 to 2009. The DRA provided start up funding of $5 million for fiscal  year 2006, increasing to $50 million for each of the subsequent 2 fiscal  years, and $75 million per year for fiscal year 2009 and beyond. One of  the first activities initiated by the MIG in fiscal year 2007 was  comprehensive program integrity reviews to assess the effectiveness of  states’ activities, which involved eight, week-long onsite visits that year.  One of the last activities to be implemented was the statutorily required  National Provider Audit Program where MIG contractors review and audit  Medicaid provider claims. In fiscal year 2005, we reported that CMS  devoted 8.1 full time equivalent staff years to support and oversee states’  anti-fraud-and-abuse operations, which, in 2010, had grown to 83 out of  the 100 DRA authorized full time equivalent staff years. Table 1  describes six core MIG activities and the fiscal year in which those  activities began.
Figure 2 shows MIG expenditures by program category for fiscal year  2010. The Medicaid Integrity Institute accounted for about 2 percent of  the MIG’s fiscal year 2010 expenditures, while the National Provider Audit  Program accounted for about half of expenditures.
At the outset, the MIG recognized that effective coordination with internal  and external stakeholders was essential to the success of the Medicaid  Integrity Program. In a report issued prior to establishment of the  program, we found that CMS had a disjointed organizational structure and  lacked the strategic planning necessary to face the risks involved with the  Medicaid program. We identified the need for CMS to develop a  strategic plan in order to provide direction to the agency, its contractors,  states, and its law enforcement partners. In designing and implementing  the program, the MIG convened an advisory committee consisting of   (1) state program integrity, Medicaid, and MFCU directors from 16 states;  and (2) representatives of the FBI, HHS-OIG, and CMS regional offices.  This committee provided planning input and strategic advice and  identified key issues that the MIG needed to address, including    The MIG’s efforts should support and complement states’ Medicaid  integrity efforts, not be redundant of existing auditing efforts.    Program integrity activities of the MIG and other federal entities  require coordination with states regarding auditing and data requests.    The focus of state activities should be shifted from postpayment  audits to prepayment prevention activities.
The advisory committee also highlighted the lack of state resources for  staffing, technology, and training. CMS’s July 2009 Comprehensive  Medicaid Integrity Plan, the fourth such plan since 2006, stated that  fostering collaboration with internal and external stakeholders of the  Medicaid Integrity Program was a primary goal of the MIG.
In implementing more recent statutory requirements, CMS again stressed  the need for effective coordination and collaboration. CMS’s commentary  accompanying the final rule on the implementation of Medicaid RACs  acknowledged the potential for duplication with states’ ongoing efforts to  identify Medicaid overpayments. States have been responsible for the  recovery of all identified overpayments, including those identified since  fiscal year 2009 by the MIG’s audit contractors. The new requirement for  states to contract with an independent Medicaid RAC introduces another  auditor to identify and collect Medicaid overpayments. The Medicaid RAC  program was modeled after a similar Medicare program, which was  implemented in March 2009 after a 3-year demonstration. Because  Medicare RACs are paid a fixed percentage of the dollar value of any  improper payments identified, they generally focused on costly services  such as inpatient hospital stays. Our prior work on Medicare RACs noted  that the postpayment review activities of CMS’s other contractors would  overlap less with the RACs’ audits if those activities focused on different  Medicare services where improper payments were known to be high,  such as home health. Because Medicaid RACs are not required to be  operational until January 1, 2012, the extent to which states will structure  their RAC programs to avoid duplication and complement their own  provider review and audit activities remains to be seen.
section_title: The MIG Is Redesigning the National Provider Audit Program, Whose Returns Were Not Commensurate with Contractors’ Costs
paragraphs: In its most recent annual report to the Congress, the MIG indicated that it  was redesigning the National Provider Audit Program. According to the  MIG, the National Provider Audit Program has not identified  overpayments in the Medicaid program commensurate with the related  contractor costs. About 50 percent of the MIG’s $75 million annual budget  supports the activities of its review and audit contractors. From fiscal  years 2009 through 2011, the MIG authorized 1,663 provider audits in 44  states. However, the MIG’s reported return on investment from these  audits was negative. While its contractors identified $15.2 million in  overpayments, the combined cost of the National Provider Audit Program  was about $36 million in fiscal year 2010. The actual amount of  overpayments recovered is not known because states are responsible for  recovering overpayments and the MIG is not the CMS entity that tracks  recoveries. Actual recoveries may be less than the identified  overpayments.
The National Provider Audit Program has generally relied on MSIS, which  is summary data submitted by states on a quarterly basis that may not  reflect voided or adjusted claims payments. As a result, the MIG’s audit  contractors may identify two MSIS claims as duplicates when the state  has already voided or denied payment on one of these claims. For their  program integrity efforts, states use their own MMIS data systems, which  generally reflect real-time payments and adjustments of detailed claims  for each health care service. States are required to have a SURS  component that performs data mining as a part of their program integrity  efforts. The MIG’s review contractors use data mining techniques that  may be similar to those employed by states, and they may not identify  any additional improper claims.
Moreover, MIG officials told us that the National Provider Audit Program  did not prioritize the activities according to the dollar amount of the claim,  that is, it did not concentrate its efforts on audits with the greatest  potential for significant recoveries. Although the amount of overpayment  identified from any given audit can vary by thousands or millions of  dollars, the MIG’s comprehensive reviews of several states’ Medicaid  integrity programs show that these states identified significantly higher  levels of overpayments in 1 year than the National Provider Audit  Program identified over 3 years. For example, the number of national  provider audits (1,663) over three fiscal years was similar to the number  that New York conducted in fiscal year 2008 (1,352), yet CMS reported  that New York had identified more than $372 million in overpayments— considerably more than the $15.2 million identified through national  provider audits.
The MIG’s proposed redesign of the National Provider Audit Program  appears to allow for greater coordination between its contractors and  states on a variety of factors, including the data to be used. In fiscal  year 2010, the MIG launched collaborative audits in 13 states. For these  audits, the states and the MIG agreed on the audit issues to review and,  in some cases, states provided the MIG’s audit contractors with more  timely and complete claims data. These collaborative projects (1) allowed  states to augment their own audit resources, (2) addressed audit targets  that states may not have been able to initiate because of a lack of staff,  and (3) provided data analytic support for states that lacked that  capability. Although these activities are ongoing and the results have not  yet been finalized, such collaborative projects appear to be a promising  approach to audits that avoids a duplication of federal and state efforts. It  remains to be seen, however, whether these changes will result in an  increase in identified overpayments.
section_title: Expanded Role Offers Opportunity to Enhance State Efforts, but More Consistent Data Are Needed
paragraphs: While the MIG’s audit program is challenged to avoid duplicating states’  own audit activities, its other core functions present an opportunity to  enhance states’ efforts. The MIG’s state oversight activities are extensive  and labor intensive. Although the data collected during reviews and  assessments are not always consistent with each other, these oversight  activities have a strong potential to inform the MIG’s technical assistance  and help identify training opportunities. The Medicaid Integrity Institute  appears to address an important state training need.
subsections: section_title: MIG’s Core Oversight Activities Are Broad, but the Data Collected During Reviews and Assessments Were Not Always Consistent with Each Other
paragraphs: The MIG’s core oversight activities—triennial comprehensive state  program integrity reviews and annual assessments—are broad in scope  and provide a basis for the development of appropriate technical  assistance. However, we found that the information collected during  reviews and the information collected from assessments was sometimes  inconsistent with each other.
As of November 2011, the MIG had completed the first round of reviews  for 50 states and had initiated a second round of reviews in 10 states.  The reviews cover the entirety of a state’s program integrity activities and  assess compliance with federal regulations. In advance of the MIG’s  week-long onsite visit, state program integrity officials are asked to  respond to a 71-page protocol containing 195 questions and to provide  considerable documentation. Table 2 summarizes the topics covered in  the protocol. Typical compliance issues and vulnerabilities identified  during the reviews include provider enrollment weaknesses, inadequate  oversight of providers in Medicaid managed care, and ineffective fraud  referrals to state MFCUs.
Much of the information collected during the assessments—Medicaid  program integrity characteristics, program integrity planning, prevention,  detection, investigation and recoveries—is also collected during the  triennial comprehensive reviews. In addition, we found inconsistencies  between the information reported in the comprehensive reviews and in  the assessments for several states that were conducted at about the  same time. For example, there was a significant discrepancy for one state  in the number of staff it reported as being dedicated to program integrity  activities. According to the MIG, knowing the size of state program  integrity staff helps it to more appropriately tailor content during training  events. Improved consistency will help the MIG ensure that it is targeting  its training and technical assistance resources appropriately. Despite the  frequency of the annual assessments, the most current data cover fiscal  year 2008, which the MIG began collecting in fiscal year 2010.
Although the MIG provides states with a glossary explaining each of the  requested data elements, it is not clear that the information submitted is  reliable or comparable across states. Our review of a sample of  assessments revealed missing data and a few implausible measures,  such as one state reporting over 38 million managed care enrollees. In  other states, there were dramatic changes in the data reported from 2007  to 2008, which either raises a question about the reliability of the data or  suggests that states be allowed to explain significant changes from year  to year. For example, the number of audits in one state declined from 203  to 35.
According to MIG officials, the comprehensive reviews and the  assessments inform the MIG’s technical assistance activities with the  states. For example, we found that the MIG published best practices  guidance in 2008 after finding weaknesses in coordination between state  program integrity officials and their respective MFCU’s in a number of  states. In its report to Congress on fiscal year 2010 activities, the MIG  indicated it completed 420 requests for technical assistance from 43  states, providers, and others. The most common topics included the  National Provider Audit Program, policy and regulatory requirements on  disclosures, provider exclusions and enrollment, and requests for  statistical assistance related to criminal and civil court actions. Examples  of assistance provided to the states by the MIG included (1) hosting  regional state program integrity director conference calls to discuss  program integrity issues and best practices; and (2) helping develop a  State Medicaid Director Letter (issued in July 2010) on the return of  federal share of overpayments under PPACA.
section_title: Medicaid Integrity Institute Trains State Staff and Facilitates Networking
paragraphs: The federally sponsored Medicaid Integrity Institute not only offers state  officials free training but also provides opportunities to develop  relationships with program integrity staff from other states. The institute  addresses our prior finding that CMS did not sponsor any fraud and  abuse workshops or training from 2000 through 2005. From fiscal years  2008 through 2012, the institute will have trained over 2,265 state  employees at no cost to states. Given the financial challenges states  currently face, it is likely that expenditures for training and travel are  limited. Expenditures on the institute accounted for about $1.3 million of  the MIG’s $75 million annual budget. MIG officials told us that states  uniformly praised the opportunity to network and learn about best  practices from other states. A special June 2011 session at the institute  brought together Medicaid program integrity officials and representatives  of MFCUs from 39 states in an effort to improve the working relations  between these important program integrity partners.
In addition to the institute, the MIG has a contractor that provides   (1) education to broad groups of providers and beneficiaries, and   (2) targeted education to specific providers on certain topics. For  example, the education contractor has provided outreach through its  attendance at 17 conferences with about 36,000 attendees. These  conferences were sponsored by organizations devoted to combating  health care fraud such as the National Association of Medicaid Program  Integrity and National Health Care Anti-Fraud Association, as well as  meetings of national and regional provider organizations (hospital, home  care and hospice and pharmacy). An example of a more targeted activity  is one focused on pharmacy providers. The MIG’s education contractor is  tasked with developing provider education materials to promote best  prescribing practices for certain therapeutic drug classes and remind  providers of the appropriate prescribing guidelines based on FDA  approved labeling. The education program includes some face-to-face  conversations, mailings to providers, and distribution of materials on a  website and at conferences and meetings. These activities are  collaborative efforts with the states so that states are: aware of the  aberrant providers, participate in the education program, and can  implement policy changes to address these issues, as appropriate.
We discussed the facts in this statement with CMS officials.
Chairmen Pratts and Gowdy, this concludes my prepared remarks. I  would be happy to answer any questions that you or other Members may  have.
section_title: GAO Contact and Staff Acknowledgments
paragraphs: For further information about this statement, please contact Carolyn L.  Yocom at (202) 512-7114 or yocomc@gao.gov. Contact points for our  Offices of Congressional Relation and Public Affairs may be found on the  last page of this statement. Walter Ochinko, Assistant Director; Sean  DeBlieck; Iola D’Souza; Leslie V. Gordon; Drew Long; Jessica Smith; and  Jennifer Whitworth were key contributors to this statement.
section_title: Appendix I: Abbreviations
section_title: Related GAO Products
paragraphs: 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.
Improper Payments: Recent Efforts to Address Improper Payments and  Remaining Challenges. GAO-11-575T. Washington, D.C.: April 15, 2011.
Status of Fiscal Year 2010 Federal Improper Payments Reporting.   GAO-11-443R. Washington, D.C.: March 25, 2011.
Medicare and Medicaid Fraud, Waste, and Abuse: Effective  Implementation of Recent Laws and Agency Actions Could Help Reduce  Improper Payments. GAO-11-409T. Washington, D.C.: March 9, 2011.
Medicare: Program Remains at High Risk Because of Continuing  Management Challenges. GAO-11-430T. Washington, D.C.: March 2,  2011.
Opportunities to Reduce Potential Duplication in Government Programs,  Save Tax Dollars, and Enhance Revenue. GAO-11-318SP. Washington,  D.C.: March 1, 2011.
High-Risk Series: An Update. GAO-11-278. Washington, D.C.: February  2011.
Medicare Recovery Audit Contracting: Weaknesses Remain in  Addressing Vulnerabilities to Improper Payments, Although  Improvements Made to Contractor Oversight. GAO-10-143. Washington,  D.C.: March 31, 2010.
Medicaid: Fraud and Abuse Related to Controlled Substances Identified  in Selected States. GAO-09-1004T. Washington, D.C.: September 30,  2009.
Medicaid: Fraud and Abuse Related to Controlled Substances Identified  in Selected States. GAO-09-957. Washington, D.C.: September 9, 2009.
Improper Payments: Progress Made but Challenges Remain in  Estimating and Reducing Improper Payments. GAO-09-628T.  Washington, D.C.: April 22, 2009.
Medicaid: Thousands of Medicaid Providers Abuse the Federal Tax  System. GAO-08-239T. Washington, D.C.: November 14, 2007.
Medicaid: Thousands of Medicaid Providers Abuse the Federal Tax  System. GAO-08-17. Washington, D.C.: November 14, 2007.
Medicaid Financial Management: Steps Taken to Improve Federal  Oversight but Other Actions Needed to Sustain Efforts. GAO-06-705.  Washington, D.C.: June 22, 2006.
Medicaid Integrity: Implementation of New Program Provides  Opportunities for Federal Leadership to Combat Fraud, Waste, and  Abuse. GAO-06-578T. Washington, D.C.: March 28, 2006.
Medicaid Fraud and Abuse: CMS’s Commitment to Helping States  Safeguard Program Dollars Is Limited. GAO-05-855T. Washington, D.C.:  June 28, 2005.
Medicaid Program Integrity: State and Federal Efforts to Prevent and  Detect Improper Payments. GAO-04-707. Washington, D.C.: July 16,  2004.
Medicaid: State Efforts to Control Improper Payments. GAO-01-662.  Washington, D.C.: June 7, 2001.
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