Congress' budget aims to target Medicaid fraud. In Massachusetts, the reality is more complicated.

Boston Globe

20-05-2025

Locally, the cost of MassHealth, the state's Medicaid administrator, grew almost 50 percent in inflation adjusted dollars from 2014 to 2023, according to the
'The growth that we've seen, that line item year over year, that has to flatten,' said State Representative Marc Lombardo, a Billerica Republican.
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The proposal passed Sunday by the House Budget Committee would make it more difficult for people to apply for Medicaid, such as by requiring some beneficiaries to be employed and requiring the state to more frequently confirm MassHealth members' eligibility. The proposal could cut the national deficit by $625 billion over 10 years, according to a
by 2034, according to the CBO.
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It's a myth that there are hordes of people fraudulently receiving Medicaid benefits, experts said.
'These are right-wing rhetorical covers for kicking people off Medicaid,' said Jonathan Gruber, an MIT economics professor who specializes in health care.
Many of those who could end up uninsured are people who are eligible for Medicaid but would struggle to overcome barriers, such as additional paperwork and record keeping, which the Congressional proposal would likely create, he said.
MassHealth officials offered a 'high estimate' that the budget proposal could make Medicaid inaccessible to hundreds of thousands and could cost the state $1 billion. More people participate in MassHealth than they did a decade ago, but the increasing cost of the program is also attributable to the increasing cost of health care and because MassHealth recipients tend to have more serious health needs.
At the heart of Congressional Republicans' budget priorities are trillions in
The Centers for Medicaid & Medicare Services reported about 5 percent of Medicaid payments nationally, about $31 billion, were
About three-fourths of those improper payments are attributable to paperwork or record-keeping errors, not intentional fraud, said Timothy Hill, senior vice president for Health at the American Institutes for Research, a nonprofit that works with providers to improve health care delivery, in a recent discussion about Medicaid fraud and abuse hosted by the health policy analysis organization KFF.
'It doesn't mean a service wasn't provided, it doesn't mean somebody didn't get care,' Hill said. 'What it does mean is that the rules that the agency established for getting payment weren't followed. All those errors could be corrected.'
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When it comes to spotting true fraud, Massachusetts has a complex, overlapping screening process that involves the Office of the State Auditor, the Office of the Inspector General, the Attorney General's Office, the federal government, and MassHealth itself. They run algorithms that spot questionable billing patterns and assign state investigators to pore over records and interview MassHealth recipients, doctors, and care providers. What they find accounts for far less than one percent of the state's $20 billion MassHealth budget.
Gina Cash, a lawyer who runs the state auditor's Bureau of Special Investigations, described the process her team uses to investigate fraud. Their focus is usually on individuals improperly receiving benefits, and the work starts with hundreds of tips, reports of people whose spending habits have raised questions about whether they are eligible for the MassHealth benefits they receive. About half of those warrant investigations, including scrutiny of people's circumstances and medical conditions.
Her office identified close to
Cash received public assistance to help pay for child care when she was a young mother just out of law school and has empathy for those who need such services.
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'The solution is not to cut, it's to continue to make oversight reforms,' she said.
Experts noted fraudulent billing from providers, not individuals seeking benefits dishonestly, accounts for the vast majority of Medicaid fraud. Such cases can be prosecuted by the state Attorney General's Office Medicaid fraud unit. One recent case includes indictments against a
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Massachusetts reported 13 Medicaid fraud convictions and 21 settlements in fiscal year 2024, according to the U.S. Department of Health and Human Services
The state Office of the Inspector General focuses on specific aspects of the health insurance system, primarily looking for improper practices from providers.
In a review of MassHealth services for children with autism from 2022 and 2023, the inspector general identified more than $17 million in
'We put a decent web together with the oversight agencies in the Commonwealth,' said Jeff Shapiro, the state's inspector general.
Health policy experts noted that fraud has a specific definition: intentional deception to obtain an undeserved benefit. Waste and abuse are more subjective. Waste can involve a provider taking advantage of billing rules, but it's harder to identify. What may look like a glut of unneeded tests, for example, could turn out to be warranted after a deeper investigation into a person's medical needs.
What qualifies as abuse can also be a matter of policy preferences.
Almost all states use revenue from taxes on health care providers to support Medicaid expenses, and in the process boost their federal reimbursements. Some federal legislators say it's a way to
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Massachusetts is expected to raise $2.3 billion through these taxes in fiscal year 2025, according to the
Gruber, the MIT economist, said he generally doesn't like loopholes, but states wouldn't be able to afford coverage for poorer populations without taking advantage of this one.
'They are dramatically cutting the ability of states to take advantage to help Medicaid pay for underfunded programs,' he said.
He is infuriated, he said, about the hypocrisy of public officials who are outraged by the idea of taxpayer money wasted through Medicaid. He contrasted the rhetoric around Medicaid fraud with the decision to cut staff at the
'Catching one or two rich tax cheats would raise so much more money than we can save with these provisions,' he said.
Jason Laughlin can be reached at