The managers of the Patient Protection and Affordable Care Act (PPACA) public exchange system are trying to prove two federal watchdog agencies wrong and show that they are capable of policing the exchange enrollment process.
The U.S. Government Accountability Office (GAO) today put out a report blasting the Centers for Medicare & Medicaid Services (CMS) efforts to keep the process honest for the first PPACA exchange plan coverage for 2014.
GAO investigators looked at verification documents for 2014 PPACA exchange plan enrollments in April 2015.
Seen in that light, "CMS has assumed a passive approach to identifying and preventing fraud," Seto Bagdoyan, a GAO director, writes in a summary of GAO investigators findings. "CMS relies on a contractor charged with document processing to report possible instances of fraud, even though CMS does not require the fraud detection capabilities."
Bagdoyan cites charges from earlier GAO reports, in which investigators found that HealthCare.gov — the exchange enrollment system that CMS runs for the U.S. Department of Health and Human Services (HHS) — provided subsidized coverage for 11 of 12 fictitious GAO applicants.
Based on GAO data, it looks as if CMS had failed to resolve application inconsistencies, or conflicts between information on exchange applications that are available from other information sources, for about 431,000 exchange plan enrollees as of April 2015, Bagdoyan writes.
CMS has still not performed a comprehensive fraud risk assessment of the PPACA enrollment and PPACA tax credit subsidy eligibility determination processes, Bagdoyan said.
Investigators at another agency, the U.S. Department of Health and Human Services Office of Inspector General (HHS OIG), have recently completed two reports on "internal controls," or basic application review processes, at the state-based PPACA exchange programs in Minnesota and Washington state.
The HHS OIG investigators found that the exchanges performed some reviews well for 2014, with Washington state doing a good job of verifying whether applicants were incarcerated, according to officials in the Washington state report.
