Eliminating Fraud, Waste, and Abuse: A Keystone in Any Healthcare System


As President Donald Trump’s cabinet takes office, think tanks and industry alike are working through scenarios not only on how the Affordable Care Act (ACA) will be repealed, but what will it be replaced with and when. We can surmise that the nominated Secretary of Health and Human Services, Congressman Tom Price – the Republican physician from Georgia and House Budget Committee Chairman – will be the trusted navigator to reform the ACA, likely by way of budget reconciliation, regulatory relief, and possibly separate legislation.

In terms of any replacement, we look to Congressman Price’s Empowering Patients First Act as a potential way forward, as well as House Speaker Paul Ryan’s, “A Better Way,” both of which outline distinct alternatives to the ACA, encapsulating Medicaid, Medicare, and commercial insurance.

President Trump has offered additional potential reforms to the ACA. Among these three proposals, one thing is for sure, President Trump, Representative Price, and Speaker Ryan consistently argue that costs must be contained, and fraud, waste, abuse (FWA), and improper payments must be eliminated.

In 2011, as Congress deliberated the ACA, the Republican Governors Association also argued for robust FWA programs. They argued such programs should be the responsibility of the state, supported with federal funds, even in per capita or block grants. Enhanced funding should be provided to states for successful FWA efforts. (See the entire Republican Governors Public Policy Committee report here.)

HMS also supports measures to contain costs and root out and eliminate FWA. With error rates in Medicare and Medicaid hovering around 10%, FWA must be prioritized as a means to control costs, and most certainly before benefits, services, or even reimbursements are cut.

Saving taxpayer dollars, containing costs, embodying private sector best practices should not only be deployed in Medicaid and Medicare, but should also include the Federal Employee Health Benefit (FEHB) Plan, Veterans Affairs health benefits, and Tricare benefits – when combined cover more than 26 million individuals. These programs should contain costs by ensuring that those receiving benefits are truly eligible; that services provides are medically necessary and appropriate; and that claims are billed and paid appropriately.

U.S. taxpayers are expecting Congress and the new Administration to create greater transparency and deliver more sustainable programs. Efforts to verify eligibility for all publicly funded healthcare programs that root out fraud in a pre- and post-payment manner and recover upon dollars improperly spent are practicable steps to that end.


Christopher Fletcher is Federal Government Relations Senior Director for HMS.