CRS Report: Most Medicaid Improper Payments Stem From Documentation Gaps
A Congressional Research Service report published Oct. 7 finds that 77% of fiscal year 2025 Medicaid improper payments were caused by insufficient documentation rather than fraud or abuse, based on CMS's Payment Error Rate Measurement program. The report details the shared oversight structure among CMS, HHS' Office of Inspector General, the Justice Department, and state Medicaid agencies, including provider screening, state fraud control units, and recovery audit contractors. State fraud control units recovered $2 billion in criminal and civil cases in fiscal year 2025, while CMS integrity efforts saved $1.5 billion in fiscal year 2024. Medicaid program integrity remains on GAO's High Risk List as of February 2025, underscoring continued vulnerability to waste and mismanagement across a program covering 85 million people at roughly $949 billion in annual cost.