Politics
OPM staff shortages hinder fraud risk reviews of FEHB
Employee departures at the Office of Personnel Management are contributing to the agency’s ongoing challenges with addressing fraud risks in the Federal Employees Health Benefits program.
A new report from the Government Accountability Office dug into whether OPM had considered assessing various factors that create risks for fraud in the government’s health insurance program for federal employees. But partially due to recent staffing vacancies, OPM was unable to provide a clear answer.
OPM officials “could not explain or provide documentation as to whether these inherent risks were considered as part of the assessment process, and why the resulting fraud risk profile does not address these risks,” GAO wrote on Thursday.
Amid the overhauls that have taken place in OPM’s internal workforce over the last several months, agency officials who were previously responsible for conducting fraud risk assessments have left their jobs, according to GAO’s report.
OPM has also paused work on its enterprise risk management (ERM) efforts, GAO found, with no clear timeline for when ERM processes will resume. For the time being, OPM officials told GAO that the agency is instead prioritizing the Trump administration’s efforts to restructure the federal workforce.
Prior to 2025, OPM’s Risk Management Council was leading the agency’s efforts to assess fraud risks in the FEHB program. But after reductions in force and reorganizations across the agency, OPM officials told GAO they are now “uncertain” whether RMC will remain the lead on those efforts, or who will be in charge of fraud risk assessment work moving forward.
GAO recommended that OPM identify who will be leading its fraud risk management efforts “as expeditiously as possible.”
“Without a designated antifraud entity and clearly defined and documented roles and responsibilities for that entity … OPM does not have the structure to strategically manage fraud risks in FEHB and prioritize the ones that are most significant,” GAO wrote.
Despite the work being currently on hold, OPM previously conducted various fraud risk assessments for FEHB over the last few years, with the last one occurring in 2024. OPM’s past risk assessments focused on two areas — ineligible family members in FEHB plans, and medical providers who submit false claims to FEHB carriers. But GAO found that they do not consider nine additional factors that also put FEHB at risk of fraud.
Source: Government Accountability Office report on FEHB program, July 2025.
An OPM spokesperson did not immediately respond to Federal News Network’s request for comment. But in its written response to GAO’s report, former acting OPM Director Charles Ezell concurred with all of GAO’s recommendations to improve fraud risk assessments and said the agency intends to make changes based on the recommendations.
“OPM shares your interest in addressing the fraud risk management shortfalls of the previous administration to better respect hardworking taxpayers and improve the integrity of this important program,” Ezell wrote.
The management of fraud risks in the FEHB program have remained a challenge at OPM for years. GAO has highlighted instances of FEHB fraud dating back at least to the early 2000s. And at least since 2012, OPM’s inspector general office has reported systemic weaknesses in FEHB carriers’ management of their fraud detection and elimination programs. Additionally, a November 2019 report from OPM’s OIG called ineligible FEHB members a “known area of substantial fraud.” The OIG also included the management of improper FEHB payments on its most recent list of top management challenges for the agency.
GAO’s July 17 report comes a few years after GAO found in 2022 that OPM has been spending up to $1 billion annually on ineligible family members in the FEHB program. The 2022 report from GAO spurred OPM to make some changes to attempt to weed out ineligible participants, such as beginning to require an eligibility validation of a random 10% sample of participants.
But as OPM faces ongoing fraud risk management challenges with FEHB, the cost of running the federal health insurance program continues to climb. In fiscal 2024, the FEHB program cost the government and program enrollees $70 billion combined — a 19% increase in the program’s cost since 2022. GAO said ineligible family members who remain on FEHB plans contribute to rising FEHB premiums and make it more expensive for OPM to run the program.
In Congress, lawmakers also made a recent attempt to reduce improper payments through the FEHB program. One provision of the now-passed GOP reconciliation bill requires OPM to create a new system to assess family members enrolled in FEHB to ensure their eligibility, and remove any participants who are found to be ineligible for the program.
In June, Senate Republicans justified the provision by saying the “lax enrollment process for family members on FEHB plans has created substantial fraud by government employee health care beneficiaries.”
The post OPM staff shortages hinder fraud risk reviews of FEHB first appeared on Federal News Network.
