WASHINGTON – On Monday, U.S. Sen. Ron Johnson (R-Wis.) and U.S. Sen. Rick Scott (R-Fla.) sent a letter to Gene Dodaro, Comptroller General of the Government Accountability Office (GAO), requesting an audit of health care providers under the Federal Employees Health Benefits (FEHB) Program. Following reports on similar programs, GAO uncovered potential fraud through improper payments causing an increase in the cost of the FEHB Program.

“GAO’s previous work on similar issues in the Medicare program and the Veterans Community Care program has uncovered a number of potentially ineligible providers, flagged weaknesses in provider vetting controls, and made valuable recommendations for improving program integrity and managing the potential risk to the care of Medicare enrollees and veterans, respectively, from ineligible providers,” explained the senators.

As the largest employer-sponsored health insurance program in the country, the FEHB Program covers more than eight million federal employees, retirees and family members at annual cost of more than $59 billion.

The full text of the letter can be found here and below.

December 12, 2022

The Honorable Gene L. Dodaro

Comptroller General of the United States

U.S. Government Accountability Office

Dear Comptroller General Dodaro:

The Government Accountability Office (GAO) is currently reviewing various aspects of fraud-risk management practices regarding the Federal Employees Health Benefits (FEHB) Program. We request as a follow-on to that work, GAO perform an audit related to providers of health care services to members of the FEHB Program. GAO’s previous work on similar issues in the Medicare program and the Veterans Community Care program has uncovered a number of potentially ineligible providers, flagged weaknesses in provider vetting controls, and made valuable recommendations for improving program integrity and managing the potential risk to the care of Medicare enrollees and veterans, respectively, from ineligible providers. 

The FEHB Program is the largest employer-sponsored health insurance program in the country, covering more than eight million Federal employees, retirees, and family members at annual cost of over $59 billion.  The size and complexity of the FEHB Program heightens the risk of fraud and error. Accordingly, it is incumbent on lawmakers, the Office of Personnel Management (OPM)—which administers the FEHB program—and the health insurance carriers that provide health care services to FEHB members, to make safeguard taxpayer dollars. As such, we request that GAO:

1. Examine whether providers of health care services in the FEHB Program are deceased, excluded from participation in federal health care programs, have suspended or revoked medical licenses, or meet other relevant criteria for being inadmissible in the FEHB Program;
2. Examine the extent to which those involved in the FEHB Program (i.e., OPM, employing agencies, health insurance carriers) have controls in place, as appropriate, to identify and remove ineligible or potentially fraudulent health care service providers, and how these entities address specific fraud risks, such as the status of state licensure; and
3. Develop case study examples—if potentially ineligible providers are identified—to explain how these providers were initially approved or remained in the network. Such case studies would be complementary to the results of relevant data analyses and would help illustrate what can go wrong when ineligible or fraudulent providers are not identified and removed from the program.

Sincerely,

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