Medicare & Medicaid Reform.
Stop fraud and abuse by implementing reporting transparency and modern oversight.
A growing body of evidence shows that Medicare and Medicaid suffer from massive improper payments—over $54 billion in Medicare alone and roughly $108 billion in Medicaid—draining taxpayer resources and undermining care for vulnerable populations. Opaque rebate arrangements and fragmented reporting guidelines enable fraud, waste, and abuse to flourish. To address these challenges, we propose radical transparency through a real‑time portal, enforceable compliance checkboxes integrated into electronic health records (EHRs), and automatic red‑flag alerts tied to independent oversight. Legislative action—modeled on the bipartisan Lower Costs, More Transparency Act—can mandate these reforms to restore integrity, reduce costs, and protect beneficiaries.
Table of Contents
The Problem: Billions Lost to Improper Payments and Abuse
Medicare Improper Payments amounted to $54.3 billion in 2024, nearly 9% of total program outlays, driven largely by inconsistent billing standards and administrative errors.
Medicaid Improper Payments reached an estimated $108 billion in FY 2024—over 12% of program costs—due to outdated reporting requirements and lax oversight.
Civil settlements under the Health Care Fraud and Abuse Control program returned just $1.8 billion in FY 2023, a fraction of the total losses, highlighting enforcement gaps.
Why It Happens: Opaque Rules & Fragmented Oversight
Complex Legislative Frameworks
Medicare is governed by dozens of statutes, subregulations, and agency memos that conflict and overlap, creating loopholes for sophisticated actors.Selective Enforcement
The Anti‑Kickback Statute (AKS) is applied unevenly; safe‑harbor carve‑outs for PBMs and hospitals are often exploited, while small providers face punitive audits.Lack of Transparency
Programs like Open Payments reveal drug company payments to physicians, but lack real‐time data on rebates and discounts tied to claims.Inadequate Reporting Guidelines
Medicaid managed‐care plans only recently faced proposed rules for disclosure of payment rates and wait‑time standards, but no centralized database exists.
Solutions: Radical Transparency & Digital Compliance
Real‑Time Medicare & Medicaid Transparency Portal
- Public digital ledger displaying every rebate, discount, and third‑party incentive by dollar amount, contract terms, and statutory basis.
- No redactions—patients and providers can see if a 40% drug rebate was passed through a PBM or pocketed.
Embedded EHR Compliance Checkboxes
- At point of care, providers select applicable AKS safe harbor, upload contractual justification, and certify under penalty of law.
- Ensures claims match financial disclosures, creating a digital paper trail for every transaction.
Automated Red‑Flag Alerts
- CMS contractors deploy algorithms to flag patterns (e.g., repeated rebates from a single vendor, price anomalies).
- Triggers mandatory reports to OIG and GAO, whose findings and consent‑decrees are published publicly
Legislative Roadmap: Enact Bipartisan Reform
The Lower Costs, More Transparency Act (H.R. 5378) offers a template: it mandates price transparency across hospitals, labs, and pharmacies, and creates advisory committees for enforcement.
Senate Bill S. 891 (119th Congress) calls for MedPAC to report on PBM agreements and requires disclosure of pharmacy benefit manager rebates to CMS and the public.
We must build on these measures to require:
- Statutory real‑time portal for all financial inducements tied to Medicare and Medicaid claims
- Civil and criminal penalties for false certifications in EHR checkboxes
- Funding for integrated compliance tools and data‑sharing infrastructure
Join this initiative.
Let’s move from outrage to action. Let’s lead from the Forefront.
