Ongoing staff shortages at the Office of Personnel Management (OPM) are impeding the comprehensive assessment of potential fraud risks in the Federal Employee Health Benefits (FEHB) program.

Ongoing staff shortages at the Office of Personnel Management (OPM) are impeding the comprehensive assessment of potential fraud risks in the Federal Employee Health Benefits (FEHB) program.

The Federal Employees Health Benefits (FEHB) program, a crucial component of the U.S. government's employee benefits system, has been under scrutiny due to persistent fraud risks. The Office of Personnel Management (OPM) and its Office of the Inspector General (OIG) have been at the forefront of efforts to combat fraud in the program.

The OPM OIG plays a central role in combating FEHB fraud through investigations and complaint handling. The OIG hotline facilitates reporting by employees and the public, aiming to detect and deter fraud. However, recent staffing shortages at OPM have significantly impaired the agency’s capacity for fraud risk review in FEHB, posing a key challenge as of 2025.

The Government Accountability Office (GAO) has recently released a report examining whether the Office of Personnel Management (OPM) considered various factors that create risks for fraud in the FEHB program. The report found that OPM has been spending up to $1 billion annually on ineligible family members in the FEHB program since at least 2022.

In response to GAO's findings, OPM began requiring an eligibility validation of a random 10% sample of participants. The GAO also recommended that OPM identify who will be leading its fraud risk management efforts "as expeditiously as possible."

The GAO report also highlighted that 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. However, the report found that OPM's past risk assessments do not consider nine additional factors that also put FEHB at risk of fraud.

Senate Republicans justified a provision of the now-passed GOP reconciliation bill by stating the "lax enrollment process for family members on FEHB plans has created substantial fraud by government employee health care beneficiaries." This provision 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.

The OIG included the management of improper FEHB payments on its most recent list of top management challenges for the agency. A provision of the now-passed GOP reconciliation bill aims to address this challenge by requiring OPM to create a new system to assess family members enrolled in FEHB to ensure their eligibility.

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. However, amid overhauls in OPM's internal workforce, agency officials who were previously responsible for conducting fraud risk assessments have left their jobs, adding to the challenges faced by the agency.

A November 2019 report from OPM's OIG identified ineligible FEHB members as a "known area of substantial fraud." The report found that OPM's past risk assessments do not consider nine additional factors that also put FEHB at risk of fraud. 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 conclusion, the FEHB program has faced significant challenges in combating fraud risks. The GAO report has highlighted systemic weaknesses in FEHB carriers' management of fraud detection and elimination programs and recommended measures for OPM to address these issues. The passing of the GOP reconciliation bill aims to address some of these challenges by requiring OPM to create a new system to assess family members enrolled in FEHB to ensure their eligibility. Despite the challenges, OPM continues to emphasize fraud alerts and whistleblower protections, demonstrating a commitment to maintaining the integrity of the FEHB program.

1. The Senate Republicans have justified a provision of the now-passed GOP reconciliation bill by stating that the "lax enrollment process for family members on FEHB plans has created substantial fraud by government employee health care beneficiaries."
2. The GAO report has highlighted the importance of OPM identifying who will be leading its fraud risk management efforts "as expeditiously as possible," as well as the need for OPM to consider nine additional factors that put FEHB at risk of fraud in their risk assessments.

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