Health Care Fraud Prevention and Enforcement Act
- Sponsor
- Rep. Suozzi, Thomas R. [D-NY-3]
- Committees
- Energy and Commerce Committee (primary)
- Last action
- Sep 10, 2026
Bottom line
The bill aims to strengthen federal efforts to combat healthcare fraud and abuse by providing substantial new funding, expanding oversight authority, and improving data-matching capabilities across federal health programs.
What it actually does
This bill significantly increases funding for federal agencies involved in the Health Care Fraud and Abuse Control Program, including the Departments of Health and Human Services (HHS) and Justice (DOJ), the HHS Office of the Inspector General (OIG), and the Federal Bureau of Investigation (FBI). It expands the OIG's investigative authority to include programs under the Affordable Care Act and integrates the Children's Health Insurance Program (CHIP) into the Medicare-Medicaid data matching system to enhance fraud detection. Additionally, it clarifies definitions and reporting requirements for fraud prevention efforts.
Proponents argue
Proponents argue that this bill is a critical investment to protect taxpayer dollars, ensure the integrity of vital federal healthcare programs like Medicare, Medicaid, and CHIP, and combat the pervasive issue of healthcare fraud and abuse. They contend that increased funding and expanded authority will lead to greater fraud detection, prosecution, and recovery of improperly paid funds, ultimately reducing healthcare costs for everyone.
Opponents contend
While direct opposition to healthcare fraud prevention is rare, potential critics might raise concerns about the efficiency of current spending, the potential for increased administrative burden on legitimate healthcare providers, or the need for more targeted approaches rather than broad funding increases. Some may also question the balance between aggressive enforcement and potential impacts on patient access or provider operations.
The bill is concise and clearly structured, making it accessible for an informed reader to understand its core provisions within a short timeframe.
Section 2(a)
Increased Funding for Health Care Fraud and Abuse Control Program
This provision significantly increases the annual appropriations for various federal entities engaged in combating healthcare fraud. For fiscal year 2027, it allocates $490 million for HHS and DOJ activities, $320 million for the HHS OIG, $230 million for the FBI, $1.28 billion for the Medicare Integrity Program, and $110 million for the Medicare-Medicaid Data Match Program. These amounts are set to increase in subsequent fiscal years, with inflation adjustments after fiscal year 2029.
Supporters argue
Proponents argue that these funding increases are essential to adequately resource federal agencies in their fight against sophisticated healthcare fraud schemes, which cost billions annually. They believe this investment will yield a high return in recovered funds and deter future fraudulent activities, ultimately strengthening the financial solvency of federal health programs.
Critics contend
While direct opposition to fraud prevention funding is uncommon, some might argue that simply increasing budgets without clear performance metrics or strategic shifts may not guarantee a proportional reduction in fraud. Concerns could be raised about the efficiency of current spending and whether these funds are optimally allocated.
Tradeoffs
The primary tradeoff involves the upfront cost of increased appropriations versus the anticipated long-term savings from reduced fraud. There's also a tension between robust enforcement and the potential for increased administrative burden or scrutiny on legitimate healthcare providers.
Section 2(b)
Expanded OIG Investigative Authority to Include ACA Programs
This section amends the Social Security Act to explicitly extend the investigative authority of the Office of the Inspector General (OIG) of the Department of Health and Human Services (HHS) to include programs established under Title I of the Patient Protection and Affordable Care Act (ACA) that are administered by the Secretary. Previously, the OIG's authority in this specific section was limited to Medicare and Medicaid activities.
Section 2(g)
Inclusion of Children's Health Insurance Program (CHIP) in Medicare-Medicaid Data Match Program
This provision expands the existing Medicare-Medicaid Data Match Program (MMDP) to include data from the State Children's Health Insurance Program (CHIP) under Title XXI of the Social Security Act, starting in fiscal year 2027. This means that data from Medicare, Medicaid, and CHIP will be cross-referenced to identify patterns of fraud, waste, and abuse across these programs.
Section 2(e)
Timeliness Requirements for Annual Health Care Fraud and Abuse Control Report
This provision amends the requirements for the annual Health Care Fraud and Abuse Control (HCFAC) report to Congress. It moves the submission deadline from January 1 to April 1 each year. Crucially, if the report is not submitted by April 1, the Secretary of HHS and the Attorney General are jointly required to provide notice to relevant congressional committees, explaining the reason for the delay, and to do so annually until the report is submitted.
Clarifies the definition of 'health plan' for the purposes of the Health Care Fraud and Abuse Control Program to include both 'public and private' delivery systems and 'public or private' plans or programs.
Section 2(c)
Why it matters:This is standard legislative practice for technical clarifications. It's not necessarily evasive, but rather a precise legal adjustment to ensure comprehensive applicability.
Case for: Proponents would argue this clarification ensures that all forms of health plans, whether public or private, are explicitly covered under the fraud and abuse control framework, closing any potential loopholes and providing greater clarity for enforcement agencies.
Case against: No specific case against this technical clarification is typically made. It is generally viewed as a non-controversial measure to ensure consistent application of existing law.
Estimated impact: The impact is primarily legal and jurisdictional, ensuring broad applicability of fraud and abuse laws to all health plans, potentially leading to more comprehensive enforcement actions.
Amends the process for determining funding allocation for the Departments of Justice and Health and Human Services by changing the requirement for the Secretary and Attorney General to 'certify' the amounts to 'agree' on the amounts.
Section 2(f)
Why it matters:This is a subtle procedural adjustment. It could be seen as a refinement of inter-agency cooperation dynamics rather than a substantively buried provision, but its impact on the balance of power or negotiation style between the departments could be significant.
Case for: Proponents might argue that changing 'certify' to 'agree' fosters a more collaborative and consensus-driven approach between the Secretary of HHS and the Attorney General in allocating critical anti-fraud funds, potentially leading to more effective joint strategies.
Case against: Critics might argue that 'certify' implies a stronger, more definitive approval process, and changing it to 'agree' could introduce ambiguity or allow for more protracted negotiations, potentially delaying funding or strategic decisions. It could also subtly shift the power dynamic between the two agencies.
Estimated impact: The impact is primarily procedural and bureaucratic, potentially influencing the internal dynamics and negotiation processes between HHS and DOJ regarding the allocation of fraud prevention funds. It does not directly alter the total funding amounts.