Fourteen Bills Walk into a Committee: E&C’s Medicaid Fraud Package
Nobody wants Medicaid dollars going to fraudsters.[1] That is the easy part. The harder questions are how much fraud is actually occurring,[2] whether the proposed solutions address the problem,[3] and how to strengthen program integrity without burying states and legitimate providers under another layer of reporting, auditing, and compliance.[4]
On September 29, House Energy & Commerce Committee Republicans released a majority staff report on fraud alongside a package of 14 bills under the banner “Continuing the Fight Against Fraud.” The report includes 13 legislative findings and 37 recommendations, and its target is Medicaid. The pitch is better data, tougher enforcement, and more accountability for state oversight, so fraud gets caught before taxpayer dollars go out the door.
So what do these bills actually require of states and providers?[5] How much of the math holds up?[6] And does any of this move before the congressional calendar runs out?[7]
The politics are part of the point
There is a political calculation here too.[8] Heading into the midterms, Republicans are leaning into an issue that is hard to oppose in good faith. The sponsor list is telling. Rep. Mariannette Miller-Meeks (R-IA), who leads two of the bills, is in one of the most competitive House races in the country. Putting at-risk incumbents out front on fraud prevention gives them a message to take home: they are protecting taxpayers and safeguarding programs for the people who depend on them.
The polling explains the timing. A recent KFF poll found that 54% of Republican voters considered fraud in government programs “extremely important” for candidates to discuss. Democratic voters were more focused on the cost of living, the future of Medicare, and health care costs, and independents ranked health care costs ahead of fraud. The same poll found that seven in ten voters would prioritize making sure eligible Medicaid enrollees can get needed care over preventing fraud, if fighting fraud meant some eligible people could lose access.
That split shapes each party’s strategy. Republicans are using fraud to talk about fiscal accountability without revisiting the more complicated consequences of the Medicaid changes they voted for in HR 1. Democrats argue the crackdown is a thinly veiled justification for cutting coverage and services, and they are betting voters care more about those consequences than about the fraud message. Which leads to the real question: will this package meaningfully reduce fraud and improper payments while protecting access, or is program integrity just another proxy for the fight over Medicaid’s future?
Improper payments vs. fraud
The committee’s report argues that fraud is a nationwide problem, that states vary widely in oversight and enforcement, and that Medicaid and Medicare have relied too heavily on “pay and chase,” recovering money after the fact instead of catching suspicious activity before claims are paid.
Medicaid fraud is real. But an improper payment is not automatically a fraudulent one. Improper payments include payments in the wrong amount, payments without sufficient documentation, and other errors. Fraud involves intentional deception. The categories can overlap, but they are not interchangeable. Screening and investigations target wrongdoing, better claims systems and clearer billing rules target errors, and more audits might catch both. All of them can also consume significant resources without reducing actual fraud.
Treating every improper payment as evidence of fraud confuses the scale of billing errors with the scale of criminal activity. That distinction should shape how policymakers size the problem and whether their solutions are appropriately targeted.[9]
$521 billion in fraud?
Most coverage led with “$521 billion lost to fraud every year.” That’s a doozy, so it’s worth reading the fine print.[10] The figure is the high end of a 2024 GAO estimate of fraud losses across all federal programs, which ranged from $233 billion to $521 billion. The committee’s own report notes that no estimate exists specifically for Medicare and Medicaid.
The report also leans on spending growth. It notes that Medicaid averages 30.7% of state budgets and projects California’s Medi-Cal spending will reach $219.7 billion by 2027, up from $83 billion in 2014. But growth is not fraud. A bigger program often has bigger improper payments at the same error rate.
What’s in the package?[11]
The TL;DR is incentives for states, deliverables for states, and a lot more paperwork for everyone.
1. Better data and more ways to use it
Four bills would expand the data and technology available to states and federal officials.
SMART Act (Rep. Troy Balderson, R-OH): requires HHS to make standardized data analytics technology available to states to identify potential fraud, waste, and abuse.
Public Access to HHS Health Data Act (Rep. Cliff Bentz, R-OR): creates a centralized, publicly accessible repository of HHS datasets.
STOP Medicaid Fraud Act (Rep. Gabe Evans, R-CO): expands electronic visit verification (EVV) requirements[12] to non-emergency medical transportation (NEMT) and applied behavior analysis (ABA) services.
Medicaid Integrity Improvement Act (Rep. John Joyce, R-PA): requires Medicaid Fraud Control Units (MFCUs) to conduct annual audits focused on higher-risk providers.
“If you’ve seen one state’s Medicaid program, you’ve seen one state’s Medicaid program.” Inconsistent state systems make it hard to spot suspicious billing across providers, service types, and states, and standardized analytics could help flag unusual claims before they are paid. But a flag is not fraud. Analytics can spot an unusual pattern, but they can’t tell you whether a claim was fraudulent, medically necessary, or properly documented. For providers serving people with disabilities, unusual patterns often reflect legitimate differences in individual needs.[13] The value of these tools will depend on data quality, the criteria used to flag claims, and investigators’ ability to tell suspicious activity from appropriate care.
2. Stronger enforcement and financial incentives to recover money
Five bills try to make fraud-fighting pay.
HELP STATES Act (Rep. Tom Kean, R-NJ): lets states keep up to 25% of the federal share of certain fraud-related overpayment recoveries, if the money is reinvested in program integrity.
Medicaid Fraud Fighting and Taxpayer Protection Act (Rep. Morgan Griffith, R-VA): raises the additional federal recovery share for states with qualifying False Claims Act cases from 10 to 25 percentage points.
Medicaid Whistleblower Protection Act (Rep. Mariannette Miller-Meeks,[14] R-IA): requires states to establish protections for people who report Medicaid fraud, waste, or abuse.
WALZ[15] Act (Rep. Mariannette Miller-Meeks,[16] R-IA): requires the HHS Office of Inspector General[17] to review whether a 10% increase in Medicaid spending may be attributable to fraud, waste, or abuse.
STOP FRAUD in Medicaid Act (Rep. Derek Schmidt, R-KS): gives MFCUs more flexibility and tools to investigate and prosecute fraudulent Medicaid applications and benefit receipt.[18]
States are more likely to invest in enforcement if they keep more of what they recover, and investigations are expensive, so the logic holds. But recoveries are easy to measure and prevention is not. The question is whether these incentives drive effective investigations and lasting improvements, or simply reward a higher volume of audits and recoveries.
3. More accountability for states
The final five bills add requirements for states to assess risk, oversee providers, and document their program integrity work.
Medicaid Integrity and Fiscal Accountability Act (Rep. August Pfluger, R-TX): requires each state to designate an official responsible for key financial integrity functions, including claims processing, payment integrity, financial reporting, and internal controls.
Medicaid Fraud Prevention Act (Rep. Michael Rulli, R-OH): requires annual state fraud risk assessments, corrective action plans, and reporting to HHS and Congress.
Medicaid RAC Improvement Act (Rep. Gus Bilirakis, R-FL):[19] strengthens oversight of Medicaid Recovery Audit Contractor programs, extends requirements to managed care payments, standardizes reporting, and phases out exemptions.
HCBS Anti-Fraud Reporting Act of 2026 (Rep. Bob Latta, R-OH): requires annual state reports on fraud, waste, and abuse in Section 1915(c) HCBS waiver services and the steps taken to address it.
Medicaid Provider Screening Accountability Act (Rep. Nick Langworthy, R-NY): requires states to check databases for providers terminated from Medicare, other state Medicaid programs, or CHIP at enrollment and reenrollment, and at least monthly after that.
These proposals would make program integrity a more formal, visible responsibility for state Medicaid agencies, which could improve consistency across states and make sure identified vulnerabilities lead to corrective action. But risk assessments, reporting systems, audits, and monthly database checks all take staff time, technology, and coordination. Those costs don’t automatically outweigh the benefits, but they aren’t inconsequential either.
What does this mean for Medicaid stakeholders?
The package mostly regulates states, but states tend to pass the burden down to providers.
HCBS reporting: The Latta bill adds an annual state report on fraud, waste, and abuse in 1915(c) waiver services. Expect states to ask providers for the underlying data, and watch whether those reports separate confirmed findings from allegations.
EVV expansion: Extending EVV to NEMT and ABA adds a documentation burden for providers who don’t use it today. What has to be captured, and how would exceptions work?[20]
Provider screening: Monthly checks against termination databases mean a provider’s status can change with little notice. Clean enrollment records matter more than ever.
Audits: Annual MFCU audits of high-risk providers, plus RAC oversight extended to managed care, mean more audit activity and more records requests. That could also reshape relationships among states, managed care organizations, audit contractors, and providers.
Incentives: If states keep more of what they recover, expect more recovery programs and more scrutiny, including of legitimate but poorly documented claims.
All of this comes back to one question: will these new compliance costs be funded, or just assigned to states and providers? And if that money comes out of existing budgets, what happens to access to services for people on Medicaid? Nothing in the committee’s report answers that.
What next?
The near-term outlook is limited. The bills were introduced in late September and referred to committee, and with the House on recess until after the midterms, there is almost no chance the package advances before voters head to the polls.
The Lame Duck offers some opening. If Republicans keep the House, they could move selected bills or fold program integrity provisions into a larger year-end package. If either chamber flips, that changes everything. The current majority may want to move priorities[21] while it still can, and an incoming Democratic majority would have very different ideas about Medicaid oversight.
Not every bill is a partisan fight. Provider screening has precedent: in 2024, the House unanimously passed a bill requiring states to check federal databases for providers barred from Medicare. Screening, data sharing, and reporting are the likeliest candidates for bipartisan action, while financial incentives and prosecution authority will likely split along party lines.
Committee hearings, revised bill text, year-end negotiations, and administration announcements will signal which ideas are gaining traction. Passed or not, these policies could shape the next Congress’s oversight agenda. The question for the Lame Duck is whether Republicans want to enact targeted Medicaid safeguards or just keep the issue in front of voters.[22]
Footnotes
[1] Well, except probably the fraudsters themselves.
[2] Answer: basically the same amount that has been occurring under Biden, Trump 1, Obama, etc.
[3] No
[4] Probably not a way
[5] Spoiler: A LOT of paperwork
[6] Definitely not 100%
[7] I highly doubt it
[8] As we’ve said before, it was never really about the fraud.
[9] Surprise! They are not appropriately targeted.
[10] Not usually my favorite thing to do
[11] That’s what she said
[12] Audible groan. If you know you know.
[13] One might even call it person-centered
[14] No relation
[15] See what they did there? WALZ, as in the Minnesota governor who was also the most recent Democratic VP candidate. Super subtle.
[16] She must really hate fraud
[17] Didn’t DOGE fire all those people?
[18] Now we’re going after the actual people getting Medicaid
[19] To give him credit, he’s had this bill out for a while
[20] Spoiler: They didn’t get that far
[21] Even this is a long shot. House Republicans have trouble agreeing on anything, even among themselves.
[22] My bet is the election part.