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Member Research and Reports

Member Research and Reports

GW: New Report Finds Fraud and Abuse Legal Framework Must Be Modernized to Better Align with Medicare Advantage

The Medicare program continues to transform to better support high-quality value-based care, yet the federal fraud and abuse legal framework has not kept pace with that shift, according to a paper published today by researchers at the George Washington University Milken Institute School of Public Health (Milken Institute SPH).

The authors highlight challenges associated with application of the current fraud and abuse framework to the Medicare Advantage program specifically and the importance of protecting against Medicare fraud and abuse while encouraging innovative healthcare payment and delivery systems.

The researchers note that there are a number of ways that policymakers could adjust the current fraud and abuse system to ensure that it works more effectively with capitated payment models.  Whether the recommendations in this paper or others are pursued, the legal and regulatory framework must be modernized as health care delivery and payment models continue to evolve to a value-based system, the authors said.

“Medicare is rapidly shifting away from the traditional fee-for-service model to capitated and other payment systems that can offer beneficiaries higher value health care,” said Ms. Jane Hyatt Thorpe, a professor of health policy and management at Milken Institute SPH, and one of the authors of the analysis. “At the same time, we must modernize the legal and regulatory framework so that it keeps up with innovative payment models that are focused on quality and outcomes of care.”

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