CMS Administrator Mehmet Oz, M.D., on Tuesday previewed the agency's next steps in its effort to root out fraud, waste and abuse in Medicaid.
The head of the Centers for Medicare & Medicaid Services said during a session at Politico's Health Care Summit that later this week, the agency will require every state to formulate a plan to revalidate participating Medicaid providers, particularly those in "high-risk" areas.
Oz said that, for example, there may be a state where 5,000 providers are listed as offering services, but fewer than a fifth of that number actually respond to queries about their identities and whether they're licensed to offer that care. That should raise alarm bells that there may be illegitimate actors involved, he said.
Oz said that states would have 30 days to submit a plan on how they would tackle the revalidations.
"The basic thing you'd want to do, if you actually cared about the program, is to make sure that legitimate providers are providing services that you're paying for and doing it the right way," Oz said. "So we're asking the states to own that problem."
CMS has focused on combating fraud in specific states, such as Minnesota, where the agency said it could withhold $2 billion in funding for the state this year and pull back millions that were provided in 2025. CMS expanded into other states, such as California and New York, as part of its push against fraud. However, CMS' recent acknowledgment of an error regarding its fraud claims in New York has raised concerns that the administration is rushing to conclusions and undercutting opportunities to address the issue collaboratively with local programs.
Oz said during the Politico event that he has heard concern in both red and blue states about illegitimate providers. Addressing this challenge gives states a chance to show that they take this issue as seriously as CMS does.
"They don't want widespread fraud, but oftentimes they're not quite sure how to get their arms around it," Oz said. "So this is a step as an example of what we'd like them to do to prove that they're serious about this."
He said that states will be expected to submit plans within the month, but didn't provide additional details on what a timeline could look like beyond that. Oz did acknowledge that an initiative like this "takes time and effort."
Oz said that if states don't take the agency's request seriously and put forth the effort necessary to build a workable plan, that will indicate to federal officials where they may next escalate their audits in specific states.
"I believe this audit and others like it will save the programs we care most about," he said.