Insight

Medicare C&D Audit and Enforcement: A look back and look ahead

Biden Administration could increase Medicare audit and enforcement in the years ahead: a review of the data

Larry Kocot

Larry Kocot

Principal, Advisory, KPMG LLP

+1 202-533-3674

As the Biden Administration prioritizes its healthcare agenda, we can expect to see a more activist federal government response to COVID-19 and on improved access to health care. Additionally, we can anticipate increased scrutiny of healthcare costs and increased healthcare regulatory enforcement activity, particularly in the Medicare Program, as enforcement priorities are evaluated and subject to change.

The inevitable demand for public accountability for the huge increase in federal spending on Medicare due to the COVID-19 pandemic, along with the billions in HHS conditional grants to healthcare providers, is likely to intensify the focus on healthcare fraud, waste and abuse more generally. Indeed, the current Administration recently announced the creation of the False Claims Act Working Group in December to enhance its partnership with the Department of Justice and HHS Office of the Inspector General to “combat fraud and abuse by identifying and focusing resources on those who seek to defraud the American taxpayers.” In its announcement about working group, HHS noted that it provided $1.5 trillion in grants and payments in 2020.

With the nomination of California Attorney General, Xavier Becerra, as HHS Secretary, industry observers expect closer HHS collaboration with the Justice Department to crack down on fraud, waste, and abuse, as well as closer scrutiny of mergers and acquisitions by the Federal Trade Commission. Given Becerra’s aggressive litigation experience and conventional wisdom that Democratic administrations are more likely to focus on white collar enforcement, it is likely that the Biden Administration will pick up where the Obama Administration left off and use its administrative authority to more aggressively monitor Medicare regulatory requirements on private plans, which could lead to more regulatory enforcement and civil monetary penalties (CMPs) to support program integrity in the Part C & D programs.


 

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