What GAO Found GAO has designated Medicare a high-risk program due, in part, to its complexity and potential for fraud. Fraud schemes in traditional Medicare often focus on certain services, such as durable medical equipment. Fraudsters may use stolen or inappropriately obtained Medicare beneficiary identifiers to submit fraudulent claims for unneeded or never provided services. The Centers for Medicare & Medicaid Services (CMS), which oversees Medicare, uses data analytics on claims in traditional Medicare to identify anomalous patterns indicative of emerging fraud schemes and potentially fraudulent behaviors, such as billing spikes. CMS uses these analytics to develop leads for investigations and to inform administrative actions that can prevent potentially fraudulent payments, such as suspending provider payments. For example, in 2023 and 2024, CMS suspended payments to, and later revoked the enrollment of, 15 providers involved in a scheme that allegedly billed Medicare for more than $4 billion in urinary catheters that were never supplied. Selected private payers GAO spoke with reported using data analytics in ways similar to CMS—namely, to identify anomalous provider billing patterns to generate leads for investigations and to inform actions like payment suspensions. CMS estimates that from fiscal years 2022 through 2024, it prevented a total of $11.9 billion in potentially fraudulent Medicare payments by taking administrative actions on providers engaged in potential fraud. Administrative Actions and Estimates of Potentially Fraudulent Payments Prevented by CMS, Fiscal Years 2022 through 2024 Administrative action Prevented payments (in millions) Prepayment claims reviews $27 Automated prepayment denials $132 Overpayment recoveries $652 Payment suspensions $2,579a Revocations and deactivations $7,962a Law enforcement referrals $554b Total $11,906 Source: GAO analysis of Centers for Medicare & Medicaid Services (CMS) data. | GAO-26-107799 Note: For more details, see Table 3 in GAO-26-107799. aProjected amount of potentially fraudulent payments prevented based on estimated cost avoidance. bEstimated amount in financial judgments that courts may order on behalf of Medicare. In December 2025, CMS began sharing information about Medicare provider payment suspensions with supplemental payers—private plans and state Medicaid agencies that cover certain Medicare beneficiaries’ out-of-pocket expenses. CMS did not share such information previously. This lack of information sharing led some supplemental payers to pay beneficiary cost sharing on potentially fraudulent claims. Representatives of private payers estimated that private plans may have paid tens of millions of dollars in beneficiary cost-sharing for the urinary catheter scheme. GAO’s analysis found that state Medicaid agencies paid at least $196,000 in state and federal funds for cost-sharing payments for the urinary catheter scheme in 2023 and 2024. Why GAO Did This Study CMS is responsible for ensuring the integrity of the Medicare program and preventing and mitigating potential fraud. GAO was asked to review CMS’s use of data analytics to prevent and reduce fraud in traditional Medicare. This report describes characteristics of common Medicare fraud schemes, CMS’s use of data analytics to identify Medicare fraud, and CMS’s estimates of potentially fraudulent payments it prevented; and examines the extent to which CMS shares information on payment suspensions with relevant entities. GAO reviewed CMS documentation on its activities to prevent fraud and interviewed CMS officials and program integrity contractors that investigate Medicare fraud about common Medicare fraud schemes and their use of data analytics. GAO also analyzed CMS data on administrative actions and the extent of potentially fraudulent payments prevented for fiscal years 2022 through 2024. Data from 2024 were the most recent data available at the time of GAO’s review. For additional context on CMS’s use of data analytics, GAO interviewed representatives of selected private health insurers and two organizations representing private payers about their use of data analytics. GAO also interviewed CMS officials and private payers about the sharing of information on payment suspensions with supplemental payers. The Department of Health and Human Services provided technical comments, which GAO incorporated as appropriate. For more information, contact Leslie V. Gordon, GordonLV@gao.gov, or Seto J. Bagdoyan, BagdoyanS@gao.gov.

What GAO Found The Infrastructure Investment and Jobs Act of 2021 (IIJA) required the U.S. Department of Transportation (DOT) to establish the Office of Multimodal Freight Infrastructure and Policy (Multimodal Freight Office, or Office). Its responsibilities include coordinating with other agencies, states, and the private sector; assisting cities and states to improve freight mobility; and carrying out the goals of the national multimodal freight policy. The IIJA directs the Multimodal Freight Office to administer certain policies and programs, such as developing and managing the National Freight Strategic Plan and the National Multimodal Freight Network, which connects highways, railroads, and maritime routes. DOT has taken steps toward meeting almost all of its statutory requirements. For example, DOT plans to release an updated National Freight Strategic Plan in 2026 and is updating the National Multimodal Freight Network. U.S. National Multimodal Freight Network DOT has not completed one of the office’s statutory requirements–periodically reporting to Congress on the activities of the Multimodal Freight Office. Officials stated that the Office had not done so because it had limited staff and was focused on other activities. While the Office briefed congressional staff in 2023, without periodic reporting, Congress has limited visibility into the activities the Office has conducted since then. Having recent information is important as Congress considers how the Office could support federal surface transportation programs, and any potential legislation related to the upcoming reauthorization. To prevent potential duplication when forming the Multimodal Freight Office, DOT formed a task force in 2023 to review multimodal freight responsibilities across the department. The task force established complementary roles between the office and other DOT administrations, according to DOT officials. DOT officials and transportation industry associations GAO met with said they found the Office helpful as a single point of contact able to respond to freight-related incidents and could help address freight issues, such as the nationwide shortage of truck parking for commercial drivers. Why GAO Did This Study The U.S. freight transportation network is vital to the nation, moving over 20 billion tons of freight in 2024 over an extensive, interconnected network. DOT is responsible for ensuring the safe, efficient, and reliable movement of freight over this network. The IIJA included a provision for GAO to review the activities of the Multimodal Freight Office. This report examines (1) the progress DOT has made in meeting its statutory requirements related to the Multimodal Freight Office and (2) how DOT identified and managed any areas of duplication and improved efficiency for freight issues across the department when establishing the Multimodal Freight Office. GAO interviewed DOT officials on steps taken toward meeting the statutory requirements. GAO analyzed internal DOT documents on the agency’s activities to manage any duplication and improve efficiency in multimodal freight efforts when establishing the Multimodal Freight Office. GAO also interviewed DOT operating administration officials; four stakeholders from the trucking, railroad, air, and maritime freight transportation industries; and one state transportation association on their views on activities of the office. GAO selected these stakeholders, as they represent the major modes of freight transportation in the U.S., per DOT’s draft National Multimodal Freight Network.

What GAO Found Several factors limit the operations of Guam’s Customs and Quarantine Agency (CQA). For example, CQA maintains only paper-based records of customs transactions, which officials said limits efficiency, may compromise data reliability and result in reduced revenue. In August 2025, CQA received funding to implement an automated customs system. Nonfunctional equipment and procurement delays also limit CQA’s operations. For the past 3 years, CQA has had only one working x-ray machine, resulting in time-intensive manual cargo inspections. GAO identified several considerations for evaluating three selected alternatives to Guam’s current customs model: (1) Guam joins the U.S. customs territory, with U.S. Customs and Border Protection (CBP) administering Guam customs (federalized model); (2) Guam remains outside the U.S. customs territory, with CBP administering Guam customs (hybrid model); or (3) Guam retains its current customs model, with additional funding for CQA from higher fees for incoming passengers or cargo. Considerations include the following: Legal changes and funding sources. In the federalized model, federal law would have to be amended for Guam to join the U.S. customs territory. In the federalized or hybrid model, a source of funding for CBP operations in Guam would need to be identified. Jurisdiction and security. In the federalized model, CBP would not inspect cargo from the U.S. customs territory. CQA officials said this could increase the risk of illegal drugs entering Guam, as most are smuggled from other parts of the U.S. Also, in the federalized model, Guam’s ports would need to be upgraded to meet all federal security requirements. Changes to Guam’s current customs model could also affect Guam’s economy. In the federalized model, imports from foreign countries would be subject to U.S. tariffs, while Guam currently does not impose tariffs. Because manufacturing in Guam is limited, this would likely raise the prices of goods on the island. In Guam’s current model with additional funding for CQA, raising passenger fees to increase CQA funding would likely reduce the number of travellers from some countries to Guam. This, in turn, would likely reduce tourism revenue, which is vital to Guam’s economy. Potential Economic Effects if Guam Adopts One of Two Selected Alternative Customs Models Why GAO Did This Study Guam, a U.S. territory in the Indo-Pacific, serves as a strategic U.S. shipping and military hub. Being outside the U.S. customs territory, Guam is not subject to U.S. federal customs administration and may impose its own tariffs on imports. CQA, which administers Guam’s customs operations, is intended to fund its operations through fees collected from incoming passengers and for cargo imports. However, a drop in tourism since 2020 has reduced its revenue. GAO was asked to examine CQA’s operations as well as alternatives to Guam’s current customs model. This report describes (1) factors that limit CQA’s operations, (2) considerations for evaluating selected alternative customs models for Guam, and (3) potential economic effects if Guam adopts one of the selected alternative models. GAO analyzed documents provided by Guam and U.S. agencies. GAO also interviewed agency officials and stakeholders in Washington, D.C.; Guam; Puerto Rico; and the U.S. Virgin Islands (USVI). GAO selected Puerto Rico and USVI to examine customs models used in other U.S. territories. CBP administers customs in Puerto Rico, which is in the U.S. customs territory and therefore uses U.S. tariffs. CBP also administers customs in USVI, which is not in the U.S. customs territory and sets its own tariffs. GAO analyzed these models, as well as Guam’s current model with additional CQA funding, as possible alternatives for Guam customs operations. GAO also conducted economic analyses to estimate the effects of Guam’s adopting one of the selected models. In comments on a draft of this report, the Office of the Governor of Guam and CQA raised concerns about the scope of GAO’s review. GAO believes its scope was appropriate to answer the report’s objectives. For more information, contact Nagla'a El-Hodiri at elhodirin@gao.gov.

What GAO Found The Veterans Health Administration’s (VHA) Caregiver Support Program offers mental health support, among other benefits, to eligible caregivers who provide around the clock care for veterans with serious injuries. This includes support groups and respite care. In fiscal year 2025, VHA data show the program served about 98,000 caregivers. In addition, VHA obligated $2.6 billion to implement the program, according to officials. VHA officials told GAO the program has grown significantly since fiscal year 2021 due in part to expanded eligibility criteria that allowed more caregivers to participate as of October 1, 2020. Caregivers Participating in Veterans Health Administration Caregiver Support Program, Fiscal Years 2021 Through 2025 VHA advertises the Caregiver Support Program through various methods, such as email updates and brochures at Department of Veterans Affairs (VA) medical centers. Some caregivers GAO interviewed said they learned about the program through these methods. However, they wished they had learned about it sooner. They also felt other caregivers did not know about the mental health support available to them through the program. VHA established four goals to assess whether its outreach efforts are effective at increasing caregivers’ awareness of the program. One goal is to increase program enrollment by 15 percent each fiscal year. However, the other three goals, such as increasing subscribers to its email updates, do not have quantitative targets and time frames. Setting targets and time frames for these goals would better enable VHA to measure its progress in increasing awareness of the program among caregivers who are not enrolled, help the agency assess how well its outreach efforts are working, and make any needed adjustments. VHA has also taken steps to assess how the program supports caregivers by establishing a goal to increase telehealth appointments by 10 percent in fiscal year 2025. VHA collects data on these appointments, which increased by 50 percent from fiscal year 2024 to 2025. However, the agency has not established goals and collected related data for other program services, such as other types of mental health treatment. Setting goals and collecting more complete information would better position VA to assess program performance. VHA could make any needed adjustments to further support caregivers’ wellbeing, allowing it to better support veterans. Why GAO Did This Study Several factors, including the demands of their care duties, can affect caregivers’ mental health and wellbeing. Research suggests that such caregiving can be linked to high levels of stress and burden and can result in depression or anxiety. The Senator Elizabeth Dole 21st Century Veterans Healthcare and Benefits Improvements Act includes a provision for GAO to review mental health support provided by the VHA Caregiver Support Program. This report examines VHA’s efforts to make caregivers aware of the mental health support available to them and VHA’s efforts to assess program performance, among other objectives. GAO reviewed VHA documentation and data for fiscal years 2021 through 2025. GAO also interviewed VHA officials, program staff and selected caregivers at four VA medical centers, and representatives from four organizations serving veterans and caregivers. GAO selected the medical centers based on program size, geography, and rurality. GAO selected organizations that focus on caregivers and have national reach. GAO also conducted a literature search and review of relevant research.

What GAO Found For about a quarter of the major rules issued from January 21, 2021, to January 20, 2025 (119 of 462 rules), agencies published effective dates inconsistent with the Congressional Review Act’s (CRA) 60-day waiting period. The waiting period begins when the Federal Register has published the rule or the House and the Senate have received paper copies, whichever is later, and does not apply under certain exceptions, such as when agencies claim good cause. Example of 60-Day Delay for a Major Rule The CRA requires rules to be received by Congress but does not further define what constitutes receipt by Congress or establish what must occur for the House and the Senate to receive a rule. Officials from all four agencies described challenges with understanding what counts as the date Congress receives copies of rules. Amending the CRA to be more precise about the date of receipt, such as by specifying that receipt occurs when agencies deliver rules to an identified office or location, would help allay the confusion agencies face. Doing so would promote the CRA’s goal of ensuring a specific minimum delay in the effective dates of major rules. Department of Energy (DOE) officials told GAO that they set effective dates for some major rules at 75 days from the date of publication in the Federal Register, instead of 60 days, which allows Congress additional time to process and receive the rules. However, no department policy formalizes this practice. GAO found that both DOE and the Department of the Treasury could have increased the number of major rules with effective dates consistent with the CRA by routinely allowing this additional time. The Department of Health and Human Services (HHS), unlike the other selected agencies, sometimes uses a different date to start the clock on the 60-day delay period. HHS officials told GAO that for some rules, they set the effective date 60 days from the date the Federal Register displays a version of the rule for public inspection, instead of using the date of official publication, as the CRA requires. HHS officials stated they did so because these rules are long and complex and can take weeks to process for publication. As a result, Congress had less time to consider these rules before they were put into effect. Why GAO Did This Study Under the CRA, rules that are likely to have large economic impacts (major rules) are subject to a 60-day waiting period before they can take effect. In previous reports, GAO found that agencies frequently set effective dates (i.e., the dates when rules are to take effect) earlier than allowed by the CRA. GAO was asked to examine agencies’ implementation of the CRA’s 60-day delay for major rules. This report examines, among other issues, (1) the number of major rules issued from January 21, 2021, to January 20, 2025, with stated effective dates inconsistent with the CRA; and (2) challenges selected agencies experienced in setting dates consistent with the CRA. GAO identified rules with stated effective dates inconsistent with the CRA using its major rule reports, the Federal Register, and the Congressional Record. GAO selected four agencies with the largest number of rules that were inconsistent with the CRA—the Department of Agriculture, DOE, HHS, and Treasury. GAO reviewed documentation and interviewed agency officials on their policies and challenges they may have experienced.

What GAO Found GAO’s work continues to make an impact. Executive branch agencies use GAO’s work to improve their operations, performance, and efficiency, and Congress uses it to inform key legislative decisions. For example, consistent with GAO’s recommendation to Congress, the Ending Improper Payments to Deceased People Act requires the Social Security Administration to permanently share its Death Master File with the Department of the Treasury to help prevent payments to deceased individuals. This will save millions of dollars each year. To meet congressional demand for GAO’s work, GAO is requesting $860 million in appropriated dollars for fiscal year (FY) 2027. This is a 5.9 percent increase over the FY 2026 enacted level. GAO’s FY 2027 budget request also uses $50 million in offsetting receipts, for $910 million in total budget authority for the fiscal year. The FY 2027 budget request will support 3,210 full-time equivalents, a reduction of 4.2 percent compared to FY 2026 and 10.2 percent since the end of FY 2024. With these resources, GAO will continue to focus on the priority needs of the Congress, including five key areas of importance: advancing efforts to address fraud, waste, and abuse in federal programs; evaluating national security activities; assessing the impacts of emerging science and technology issues; assessing efforts to address evolving cybersecurity threats; and analyzing health care spending. GAO also plans to make targeted, critical investments in its information technology systems, advanced analytic capabilities, and cybersecurity. To help drive efficiency, an important focus will be increasing the use of emerging technologies, including artificial intelligence. Why GAO Did This Study GAO’s mission is to support Congress in meeting its constitutional responsibilities and to help improve the performance and ensure the accountability of the federal government for the benefit of the American people. GAO’s work spans the full breadth and scope of the federal government’s responsibilities. Congress relies on GAO’s nonpartisan, objective, and high-quality work to help inform congressional deliberations as well as oversight of the executive branch. GAO routinely conducts work for the Chairs or Ranking Members of over 90 percent of all standing committees. Since 2002, GAO’s work has resulted in over $1.51 trillion in financial benefits and almost 30,800 program and operational benefits that helped create or change laws, improve public safety and other services, and promote better management throughout the government. For more information, contact Dave Powner at pownerd@gao.gov.

What GAO Found All federal programs and operations are at risk of fraud, regardless of whether they provide financial or nonfinancial benefits or delivery takes place at the federal, state, or local level. Understanding the scope of the problem is critical to combating fraud. In 2024, GAO estimated total direct annual financial losses to the government from fraud at between $233 billion and $521 billion, based on fiscal year 2018 through 2022 data. The estimate captures losses that occur at the state, local, tribal, or other government level if those losses included a federal investigative, administrative, or related action. State agencies administer federal programs, making payment, eligibility, and other decisions. In fiscal year 2025, the federal government provided an estimated $1.2 trillion to state and local governments in federal grants. The programs vary in size, but some, such as Medicaid, involve millions of beneficiaries. Decentralized program delivery such as through distributed payment and eligibility decisions can heighten the risk of fraud. GAO has previously reported that federal and state program managers’ efforts to manage fraud risks have been challenged by weak control environments, data and system limitations, and limited capacity to manage risks. For example, one state agency administering a federally funded program reported it is restricted by state and federal laws from sharing information with other programs in the state, such as information on individuals and their use of state services. This hindered the agency’s ability to prevent and detect fraud within and across programs. Federal programs, including those administered at the state level, are inherently subject to fraud risks from various entities and individuals (see fig.). Types of Organized Fraud Groups Targeting Government Programs Decentralized program delivery—where federal funds are distributed to grantees, subrecipients, contractors, and subcontractors—creates vulnerabilities to different types of fraud. For example, inspectors general previously reported that the Temporary Assistance for Needy Families block grant to states faced an increased risk of fraud because of limited visibility and control over expenditures at the award recipient and subrecipient levels. Other GAO reporting has shown that, given the opportunity, organized criminal organizations, businesses, and individuals from all walks of life have sought to defraud federal programs. Certain risk factors—such as program design, culture, and personal motivation—can also increase the risk that fraudsters will target a program. Why GAO Did This Study The U.S. federal government is one of the world’s largest and most complex entities, spending trillions of dollars across a broad array of programs and operations, with a substantial percentage of this spending administered by the states. The size, scope, and complexity of the federal government create inherent risks that need to be recognized and managed properly. Fraud is one such risk that must be managed to ensure that program delivery and taxpayer dollars are safeguarded. Every dollar or resource diverted to fraudsters hinders the federal government’s ability to achieve its goals. Financial losses also place an increased burden on the government’s financial outlook. Fraud also erodes public trust in government and hinders agencies’ efforts to execute their missions. This statement focuses on fraud in federally funded, state-administered programs by (1) outlining the scope of the problem and fraud risk landscape, (2) examining challenges facing federal and state agencies in combating fraud, and (3) examining fraud threats the government faces and why it is difficult to combat them. This statement is based on a body of work of selected reports that GAO issued between 2010 and 2026.