Program Integrity Alliance Comments on the House Energy and Commerce Committee's Fraud-Fighting Legislative Package

The House Energy and Commerce Committee’s recent Fraud-Fighting Package to Protect Vulnerable Americans and Safeguard Taxpayer Dollars includes proposals that reflect important principles of effective fraud risk management, including providing agencies with reliable information, preventive controls, clear accountability, and the capacity to identify vulnerabilities before they result in significant losses. Of the 14 bills introduced, the Program Integrity Alliance (PIA) offers comments on nine bills that align with PIA's Integrity Blueprint, highlights areas of concern, and offers targeted recommendations to strengthen the legislation's fraud prevention capabilities.

PIA strongly supports the following three bills, which we believe are key to transitioning from a pay-and chase stance to a systematic, analytics-based prevention approach.

• The SMART Act addresses the fact that states operating independently often lack visibility into suspicious activity that crosses jurisdictional and program boundaries. The SMART Act helps address that vulnerability by requiring the Department of Health and Human Services (HHS) to make interoperable fraud analytics available to every state, establish risk indicators using data from multiple Medicaid and federal healthcare programs, and deliver actionable alerts. Making analytics capacity available to states helps address the significant limitation of individual state analytics capacity. The bill does not specify how HHS would make this analytics capacity available, which is an important implementation consideration. PIA proposes using federated queries with privacy enhancing technologies (PETs) to ensure that sensitive information is protected and that the government does not rely on a centralized repository of data, which presents data security vulnerabilities.
• The Medicaid Fraud Prevention Act closely reflects PIA's emphasis on systematic fraud risk management. It requires states to systematically identify vulnerabilities, prioritize risks, and implement corrective actions, which aligns with the GAO Fraud Risk Framework. PIA proposes strengthening the proposal by requiring states to demonstrate how identified vulnerabilities translate into changes in verification, screening, or payment control, because while annual assessments are useful, rapidly evolving fraud schemes also require ongoing monitoring.
• The Medicaid Provider Screening Accountability Act, which would strengthen ongoing verification of provider eligibility. Weaknesses in provider enrollment and screening create significant opportunities for Medicaid fraud. A provider terminated from one government healthcare program should not be able to exploit another program's failure to check available exclusion information. This principle also applies to continuous, event-driven verification of provider identities, ownership, affiliations, and other risk indicators where legally authorized.

PIA also supports the following three bills.

• The Medicaid Integrity and Fiscal Accountability Act’s establishment of clear accountability for Medicaid financial integrity at the state level would establish a key control. Designating a responsible official is consistent with the Integrity Blueprint's emphasis on assigning ownership of fraud risk management and ensuring that prevention is a core management responsibility.
• The STOP Medicaid Fraud Act would expand electronic visit verification to additional Medicaid services vulnerable to fraud. Independent verification that services were delivered is an important preventive control and aligns with our Integrity Blueprint's emphasis on corroborating claims rather than relying solely on self-reported information.
• Lastly, PIA supports strengthening protections for individuals who report suspected Medicaid fraud, waste, and abuse, which the Medicaid Whistleblower Protection Act would do. Whistleblowers are an important source of information about fraud schemes and control weaknesses, and effective protections help ensure that concerns can be raised without fear of retaliation.

PIA identified reservations with the following proposals and outlines issues below.

• States need stronger resources and incentives to combat fraud, and the HELP STATES Act's requirement that recovered funds be reinvested in program integrity activities is constructive. However, financial incentives should reward preventing fraudulent payments, not just recovering them after the fact. Congress should also consider incentives tied to demonstrated fraud prevention outcomes, using credible measurement methodologies that account for false positives and protect legitimate beneficiaries.
• PIA supports greater transparency and access to government data but has reservations about the Public Access to HHS Health Data Act's approach to making federal health datasets publicly available. Greater data accessibility must be balanced with strong privacy protections, including safeguards against reidentification and inappropriate disclosure of sensitive information. The legislation must establish clear standards for determining which datasets can be released and under what conditions.
• PIA cautions against treating increases in Medicaid expenditures as presumptive evidence of fraud, as contemplated in the WALZ Act. Unusual increases in claims can be useful fraud risk indicators and warrant further examination, but spending growth may also reflect legitimate changes in enrollment, utilization, reimbursement rates, and other factors. Any review should distinguish these causes and rely on credible methodologies for measuring fraud.

See the proposed bills here: https://energycommerce.house.gov/posts/e-and-c-republicans-introduce-critical-fraud-fighting-package-to-protect-vulnerable-americans-and-safeguard-taxpayer-dollars