GOVERNOR KOTEK REFUTES MISLEADING CLAIMS ABOUT OREGON HEALTH PLAN, HIGHLIGHTS AGGRESSIVE FRAUD PREVENTION AND RECOVERY EFFORTS

The following information was released by the office of the Governor of Oregon:

Oregon's Medicaid program serves more than 1.4 million Oregonians, providing health coverage to low-income families, seniors, people with disabilities, and children

Salem, OR Governor Tina Kotek is pushing back against unsupported accusations by the Trump Administration suggesting widespread fraud in the Oregon Health Plan (OHP), Oregon's Medicaid program, emphasizing that the state already operates one of the most proactive and robust systems in the country for detecting, preventing, and prosecuting fraud.

"Oregon has been a national leader in making sure people have access to health care, and we work hard to protect the integrity of the Oregon Health Plan, which provides care to 1 in 4 Oregonians," Governor Kotek said. "We have built strong systems to detect abuse early, investigate thoroughly, and hold bad actors accountable. Our priority is making sure taxpayer dollars appropriately support Oregonians who rely on this care."

Oregon is making public its response to the inquiries of the U.S. House Committee on Energy and Commerce. The letter details extensive safeguards built into the program and highlights the results of aggressive oversight and enforcement.

Strong oversight across multiple agencies

Fraud prevention and program integrity efforts for OHP are coordinated across the Oregon Health Authority (OHA), the Oregon Department of Human Services (ODHS), and in close partnership with Oregon Attorney General Dan Rayfield's office.

These agencies use a layered approach that includes:

Provider screening and credentialing before enrollment in Medicaid

Risk-based background checks and site visits for providers

Continuous claims monitoring and data analytics to flag suspicious billing patterns

Routine and targeted audits of providers and programs

Payment suspensions when credible allegations of fraud arise

Administrative sanctions and provider terminations when violations occur

Oregon also requires Medicaid providers to undergo regular revalidation and maintains ongoing monitoring of federal exclusion databases to ensure individuals who have been sanctioned elsewhere cannot bill OHP.

Under Governor Kotek, the state has cracked down on fraud, including nearly $2 billion in tax refund fraud thwarted by the Oregon Department of Revenue announced last week.

Significant fraud recoveries and enforcement

The state's enforcement actions have delivered substantial results.

From 2021 through 2025, Oregon recovered more than $159 million in improper Medicaid payments through audits, investigations, and payment recovery programs.

In addition, the Medicaid Fraud Control Unit within the Oregon Department of Justice secured more than $54 million in recoveries from 2020 through 2025, along with 43 civil settlements and judgments against providers engaged in fraudulent activity.

"Oregon aggressively pursues fraud wherever it occurs," Governor Kotek said. "These recoveries demonstrate that our systems are working. We are identifying improper payments, recovering funds, and prosecuting those who try to take advantage of the program."

Advanced tools to detect suspicious activity

The state also employs advanced data tools to detect abnormal billing and claims patterns, including peer-to-peer provider comparisons, utilization analysis, and outlier detection.

When suspicious activity is identified, cases can trigger audits, administrative sanctions, payment suspensions, or criminal investigations through the state's Medicaid Fraud Control Unit and federal law enforcement partners.

Oregon also participates in interstate data-matching programs to identify individuals improperly receiving benefits in multiple states.

Protecting care for Oregonians

OHP currently serves more than 1.4 million Oregonians, providing health coverage to low-income families, seniors, people with disabilities, and children.

Governor Kotek emphasized that protecting the program's integrity ensures those resources remain available for the people who need them most.

"The Oregon Health Plan is a lifeline for more than a million Oregonians," Governor Kotek said. "We will continue strengthening oversight and improving our tools to detect fraud. We need a federal government that partners with us to safeguard programs people depend on, not chastise public servants and misinform the public."