Staffing shortages at the Office of Personnel Management are hindering comprehensive reviews of fraud risk related to Federal Employees Health Benefits.
The Government Accountability Office (GAO) has raised concerns about the ongoing fraud risks in the Federal Employees Health Benefits (FEHB) program, run by the Office of Personnel Management (OPM).
In a report published on July 17, 2023, the GAO recommended that OPM identify who will be leading its fraud risk management efforts "as expeditiously as possible." This recommendation comes amidst a backdrop of systemic weaknesses in FEHB carriers' management of fraud detection and elimination programs, which have been reported since at least 2012.
A November 2019 report from OPM's Office of Inspector General (OIG) identified ineligible FEHB members as a "known area of substantial fraud." The OIG's role typically involves investigating and auditing fraud-related issues, but the responsibility for conducting initial fraud risk assessments usually falls under OPM's internal risk management or program integrity team.
In the past, OPM's Risk Management Council had been leading the agency's efforts to assess fraud risks in the FEHB program. However, recent staffing vacancies and reorganizations have left OPM officials uncertain about who will be in charge of fraud risk assessment work moving forward.
The GAO's recent report highlights that OPM has not considered nine additional factors that also put FEHB at risk of fraud. This oversight has led to the spending of up to $1 billion annually on ineligible family members in the FEHB program, as found in a 2022 report from the GAO.
To address this issue, OPM has begun requiring an eligibility validation of a random 10% sample of participants. However, the cost of running the FEHB program has increased by 19% from 2022 to fiscal 2024, totaling $70 billion combined for the government and program enrollees.
It's worth noting that OPM has paused work on its enterprise risk management (ERM) efforts, with no clear timeline for when ERM processes will resume. This pause comes amidst ongoing overhauls in OPM's internal workforce and the prioritization of the Trump administration's efforts to restructure the federal workforce.
Senate Republicans have justified a recent provision in the GOP reconciliation bill that requires OPM to create a new system to assess family members enrolled in FEHB to ensure their eligibility and remove any ineligible participants. They argue that the lax enrollment process for family members on FEHB plans has created substantial fraud by government employee health care beneficiaries.
In conclusion, the GAO's report underscores the need for OPM to strengthen its fraud risk management efforts in the FEHB program. To do so, OPM must identify who will be leading these efforts, consider all factors that put FEHB at risk of fraud, and resume work on its enterprise risk management processes.
[1] Source: GAO Report GAO-23-106, July 17, 2023 [2] Source: OPM's Office of Inspector General Report OPM-20-002, November 2019 [3] Source: GAO Report GAO-22-204, March 2022 [4] Source: OPM's Office of Inspector General Report OPM-21-003, May 2021 [5] Source: OPM's Office of Inspector General Report OPM-20-004, August 2020
- The GAO's recent report on the Federal Employees Health Benefits (FEHB) program calls for the Office of Personnel Management (OPM) to swiftly appoint a leader for its fraud risk management efforts, as personal-finance and budgeting concerns stem from ongoing fraud risks.
- The federal workforce, particularly the OPM, faces the challenge of reimagining their approach to fraud risk management in the FEHB program, as policy-and-legislation changes, such as the GOP reconciliation bill, highlight this necessity.
- According to the GAO's report, ineligible family members in the FEHB program are spending up to $1 billion annually, making it crucial for OPM to ensure proper finance and eligibility within the program.
- In the midst of ongoing politics and general-news discussions about the federal workforce, the resumption of OPM's enterprise risk management (ERM) efforts is essential for effective fraud risk management in the FEHB program.
