BEYOND THE DOLLAR: MEDICAID FRAUD & IMPROPER PAYMENTS
- Robert Aery
- 22 hours ago
- 1 min read
As healthcare costs rise and patients experience strained access to care, this research sheds light on the potential for Medicaid fraud and improper payments to increase pressures on our healthcare system and impact services beyond the Medicaid program.
Medicaid fraud and improper payments are generally studied in financial terms. This report, Medicaid Fraud & Improper Payments in Context, develops a framework for translating fraud and unauthorized payments into real-world, health-system service equivalents and physician-capacity measures, providing a better understanding of their true scale and impact within our healthcare system.
SUMMARY OF FINDINGS
Medicaid fraud recoveries equivalent to approximately:
13.68 million physician visits
21.05 million prescription fills
171,009 full-year equivalent Medicaid enrollees
Improper payments equivalent to approximately:
$315 per Medicaid enrollee
311 million physician visits
479 million prescriptions
3.89 million full-year equivalent Medicaid enrollees
Physician-equivalent capacity displacement for improper payments:
10,000 to 25,000 physicians in FY2024
12,000 to 30,000 physicians in FY2025
The study emphasizes that improper payments do not necessarily represent fraud or services that did not occur. Instead, the analysis compares the magnitude of payment errors to the capacity of the healthcare system to illustrate scale relative to physician workforce constraints.
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