Anti-Fraud Efforts Should Start with the Government Customer

The U.S. Government Accountability Office’s (GAO) recent report “CMS Needs to Fully Align Its Antifraud Efforts with the Fraud Risk Framework” offers multiple recommendations for the Centers for Medicare & Medicaid Services (CMS) to improve its anti-fraud efforts.

According to the report, CMS provides health coverage for over 145 million Americans with annual outlays of about $1.1 trillion. GAO has designated the two largest programs, Medicare and Medicaid, as high risk partly due to their vulnerability to fraud, waste and abuse. In the fiscal year 2016 alone, improper payment estimates for these programs totaled about $95 billion.

The GAO report states that CMS has taken steps to create a culture conducive to fraud risk management, but could enhance and supplement antifraud training for its +4,000 employees.

This recommendation is consistent with GAO’s Fraud Risk Framework. The report states that the “Fraud Risk Framework identifies training as one way of demonstrating an agency’s commitment to combating fraud. Training and education intended to increase fraud awareness among stakeholders, managers, and employees, serves as a preventive measure to help create a culture of integrity and compliance within the agency.”

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Similarly, another government agency recently conducted research for fraud prevention strategies that engage executive leadership, management, and front-line employees to ensure that fraud, waste and abuse (FWA) is combated at its source.

In both situations, an incredibly valuable resource – tens of millions of customers – are not mentioned.

Financial institutions have used alerts for years to notify customers of low balances, account activity, and large transactions to serve the customer and engage the customer in the institution’s fraud prevention efforts. Agency executives should consider how tens of millions of customers, serving as the first line of defense against FWA, can be engaged along with employees, leadership and other stakeholders to increase program integrity and reduce FWA.