Health Care Fraud Prevention and Enforcement Act
- Sponsor
- Sen. Cortez Masto, Catherine [D-NV]
- Committees
- Finance Committee (primary)
- Last action
- Aug 6, 2026
Bottom line
The bill substantially boosts federal resources and expands the scope of anti-fraud efforts across major federal health programs, aiming to enhance program integrity and recover fraudulent payments.
What it actually does
This bill significantly increases annual funding for federal agencies involved in the Health Care Fraud and Abuse Control Program (HCFAC), including the Departments of Health and Human Services (HHS) and Justice (DOJ), the HHS Office of Inspector General (OIG), the Federal Bureau of Investigation (FBI), the Medicare Integrity Program, and the Medicare-Medicaid Data Match Program. It also expands the investigative authority of the HHS OIG to include programs under the Affordable Care Act and integrates the Children's Health Insurance Program (CHIP) into the Medicare-Medicaid Data Match Program. Additionally, it mandates a Government Accountability Office (GAO) study on the HCFAC program's performance and effectiveness.
Proponents argue
Supporters argue that increased funding and expanded authority are crucial to combat the rising tide of healthcare fraud, which costs billions annually. They contend that these investments will protect taxpayer dollars, ensure the integrity and sustainability of vital federal health programs like Medicare, Medicaid, CHIP, and ACA, and ultimately lead to a significant return on investment through recovered funds.
Opponents contend
Critics might argue that while fraud prevention is important, the proposed funding increases are substantial and should be accompanied by more rigorous, publicly available metrics demonstrating the efficiency and effectiveness of existing programs. Some may raise concerns about potential overreach of investigative authority or the administrative burden on legitimate healthcare providers and state agencies due to expanded data matching.
The bill is relatively short and its core provisions are clearly articulated, making it accessible for an informed reader to evaluate within a reasonable timeframe, typically less than 15 minutes.
Section 2(a)
Increased Funding for Health Care Fraud and Abuse Control Program
This provision significantly increases annual appropriations for key federal entities involved in combating healthcare fraud. Starting in fiscal year 2027, the Departments of Health and Human Services and Justice, the HHS Office of Inspector General, the Federal Bureau of Investigation, the Medicare Integrity Program, and the Medicare-Medicaid Data Match Program will receive substantial funding increases. These amounts will continue to rise annually, adjusted by the Consumer Price Index after fiscal year 2029.
Supporters argue
Proponents argue that these substantial investments are critical to deter and prosecute healthcare fraud, which costs the nation tens of billions annually. They assert that every dollar invested in fraud prevention and enforcement yields significant returns in recovered funds, ultimately saving taxpayer money and preserving the solvency of vital federal health programs.
Critics contend
Critics might question the efficiency of current anti-fraud programs or whether such large, sustained increases are justified without clearer, publicly available metrics of return on investment. Some may express concerns about potential over-enforcement leading to undue burdens on legitimate healthcare providers.
Tradeoffs
The provision balances the upfront cost of increased enforcement with the potential for substantial long-term savings from fraud recovery. It also navigates the tension between aggressive fraud detection and the potential for increased administrative burdens or scrutiny on legitimate healthcare providers.
Section 2(b)
Expanded OIG Authority to Include ACA Programs
This provision amends the Social Security Act to explicitly extend the investigative authority of the HHS Office of Inspector General (OIG). Previously focused on Medicare and Medicaid, the OIG's jurisdiction will now include programs established under Title I of the Patient Protection and Affordable Care Act (ACA) that are administered by the Secretary of HHS. This ensures comprehensive fraud oversight across a broader range of federal health initiatives.
Section 2(c)
Clarification of 'Health Plan' Definition for Fraud Control
This provision makes a technical amendment to Section 1128C of the Social Security Act, clarifying that the scope of the Health Care Fraud and Abuse Control Program (HCFAC) applies to both 'public and private' healthcare delivery systems and 'public or private' plans or programs. This ensures that the HCFAC program's anti-fraud efforts comprehensively cover the entire spectrum of healthcare financing and delivery, removing any ambiguity regarding its reach.
Section 2(g)
Inclusion of Children's Health Insurance Program (CHIP) in Data Match Program
This provision amends the Social Security Act to include the State Children's Health Insurance Program (CHIP) in the Medicare-Medicaid Data Match Program (MMDM) starting in fiscal year 2027. This integration will allow for cross-program data sharing between Medicare, Medicaid, and CHIP, enabling more robust detection of fraud, waste, and abuse across these critical federal and state health programs.
Adds a 'Rule of construction' clarifying that nothing in the funding paragraph limits the authority of the Secretary of HHS, the Attorney General, or the HHS Inspector General to use funds made available under the Health Care Fraud and Abuse Control Program to detect or prosecute health care fraud and abuse, or to communicate with the public about health care fraud.
Section 2(d)
Why it matters:This is standard legislative practice to clarify congressional intent and prevent potential misinterpretation or legal challenges that might narrowly define the permissible uses of anti-fraud funds. It ensures flexibility for agencies.
Case for: Supporters argue this clarification is essential to ensure that federal agencies have the broadest possible authority to combat fraud and inform the public, preventing legal challenges that could restrict their effectiveness despite increased funding.
Case against: While generally seen as a positive clarification, some might argue that such broad discretion, even for anti-fraud efforts, should be accompanied by more specific programmatic guidance to prevent potential overreach, though this is a common legislative tool.
Estimated impact: Reinforces the broad scope and flexibility of federal anti-fraud activities, potentially enhancing their overall impact by preventing legal limitations on fund usage.
Amends the annual report requirement to Congress for the Health Care Fraud and Abuse Control Program. If the report is not submitted by April 1 of the year, the Secretary of HHS and the Attorney General must jointly provide notice to appropriate committees of Congress, stating the reason for the delay, and provide annual updates until the report is submitted.
Section 2(e)
Why it matters:This amendment enhances accountability for an existing requirement, a common legislative tweak to improve oversight. It ensures Congress is informed of delays in critical program assessments.
Case for: Proponents argue that this provision significantly enhances transparency and accountability for federal agencies in providing timely oversight reports to Congress, ensuring that lawmakers have the information needed to assess the program's effectiveness.
Case against: Agencies might argue that this adds another administrative burden, requiring formal notification and ongoing updates for delays, even if those delays are due to unforeseen circumstances. However, the intent is to ensure compliance with existing mandates.
Estimated impact: Improves congressional oversight of the HCFAC program by mandating transparency around reporting delays, potentially leading to more timely and complete information for lawmakers.
Amends Section 1817(k)(3)(A)(i) of the Social Security Act by striking the word 'certify' and inserting 'agree' regarding the process by which the Secretary of HHS and the Attorney General determine the funding allocation for the Departments of Justice and Health and Human Services.
Section 2(f)
Why it matters:This subtle change alters the legal standard for inter-agency agreement on funding. 'Agree' implies a more collaborative and mutual decision-making process, requiring both parties to reach a consensus, whereas 'certify' could imply one party simply attesting to the other's decision or a pre-determined allocation.
Case for: Proponents argue that changing 'certify' to 'agree' promotes greater collaboration, shared ownership, and mutual accountability between HHS and DOJ in allocating critical anti-fraud resources, ensuring both agencies are fully invested in the funding decisions.
Case against: While generally seen as a positive step for inter-agency coordination, some might argue that requiring explicit 'agreement' could potentially lead to bureaucratic impasses or delays if the agencies struggle to reach a consensus on funding allocations, though this is a minor concern.
Estimated impact: Subtly but significantly alters the dynamic of inter-agency funding allocation for the Health Care Fraud and Abuse Control Program, fostering a more collaborative approach between HHS and DOJ.