The Office of the Inspector General (OIG) at the Department of Health and Human Services (HHS) plays a central role in identifying health care waste, fraud, and abuse. They provide oversight and recommendations to improve HHS programs, including Medicare and Medicaid.
As part of the effort, OIG has developed its Top Unimplemented Recommendations list to highlight the efforts that could produce the most substantial savings. This list of ready-made proposals would be a good place for the Trump administration to start if they are looking for more wins ahead of the November midterms.
Cracking down on Medicaid fraud has emerged as a key priority for the Trump administration in 2026, and OIG has already made several recommendations to strengthen the program. So, what moves could the Trump administration make in the future?
This blog outlines specific recommendations aligned with the Trump administration’s priorities for Medicaid, as well as the barriers to implementing these recommendations.
Recovering Medicaid Overpayments
Currently, OIG estimates that the Centers for Medicare and Medicaid Services (CMS) has not recovered over $1 billion in Medicaid overpayments. These overpayments have been found through audits conducted over the past 25 years and include multiple reporting periods. The overpayments have yet to be recovered as CMS does not have set time frame for resolving overpayment issues, does not have a verification process to ensure that states follow guidance, and does not retain documentation to support recovered overpayments.
Kimberly Brandt, CMS’s Deputy Administrator and COO, told the Energy and Commerce Oversight Subcommittee at a March 17 hearing that CMS is looking to move towards a “stop and cop” enforcement strategy as opposed to a “pay and chase” strategy, which would prevent money from being lost to fraud, rather than trying to recover it after the fact. While this change in strategy could be helpful in reducing future overpayments, CMS would still need to take additional actions to recover previous overpayments.
Reviews of Prior Authorization Denials
Prior authorization reform has been gaining traction on both sides of the aisle over the past few years. In 2023, HHS-OIG flagged the high rate of prior authorization denials for Medicaid Managed Care Organizations (MCOs), raising concerns that enrollees are not receiving all medically necessary health care services.
To address these concerns, OIG has recommended that CMS:
- Require states to review the appropriateness of prior authorizations
- Require states to collect data on MCO prior authorization decisions
- Issue guidance to states on use of MCO data for oversight
- Require external medical reviews of upheld MCO prior authorization denials
- Work to identify MCOs that may be issuing inappropriate denials
The Medicaid and CHIP Payment and Access Commission (MACPAC) has also made similar recommendations in the past. In their March 2024 Report to Congress, the Commission recommended that states establish an independent, external medical review process and for CMS to update regulations to require states to collect and report data on denials and appeal outcomes.
These actions could be enticing for the administration because they are reforms the president could point to as examples of action to address concerns about health care access and increase transparency.
Barriers to Implementation
Despite these seemingly straightforward recommendations to address health care waste, fraud, and abuse, implementation is not without challenges.
Pushback could come from stakeholders. For example, states could be unsupportive of new federal mandates that impact Medicaid administration, especially if they come with increased costs and administrative burden. States are also required to balance their budgets, which could make it more difficult to recover overpayments in the wake of Medicaid funding changes from the One Big Beautiful Bill Act or proposed increased program oversight. Additionally, MCOs are unlikely to be supportive of additional oversight over their decision-making processes, with the push back that it will increase administrative burden and delay care. Patient groups may also worry that increased enforcement will lead to improper denials or delays in getting care for enrollees.
The administration would also likely face opposition from Democratic lawmakers and potentially from more moderate Republicans. During consideration of the One Big Beautiful Bill Act, we saw moderate Republicans looking to demonstrate concerns about the impact of certain policies on access to care for Medicaid enrollees. More recently, Democratic members have raised concerns that the Trump administration is unfairly targeting Democratic states in its search to uproot health care waste, fraud, and abuse.
So, what happens now?
HHS-OIG’s recommendations are a starting point to address health care waste, fraud, and abuse. The Trump administration is reviewing some of the recommendations from the list, with an update expected in August. However, a key question is can the administration persuading sell the anti-fraud efforts as also effective in addressing health care affordability concerns. The answer to that question could have implications for who controls Congress next year.