The Office of Personnel Management recently made headlines by requesting health claims data for workers covered under the Federal Employees Health Benefits (FEHB) program.
The government needs this itemized data to ensure health plan billing and payment integrity. The information empowers plan administrators and members to compare prices and reconcile whether the billed and paid amounts are accurate and match the plan’s negotiated rate.
This data access can give OPM the tools to identify and prevent significant overpayments that are driving cost overruns. These receipts of payment can expose provider overcharging, upcoding, double-billing, false claims, ineligible payments, and failures to coordinate benefits when a member has other coverage.
Claims information can also reveal when insurance carriers — like Blue Cross Blue Shield, which covers over two-thirds of FEHB members — make payments based on higher billed charges rather than negotiated rates. It can surface spread pricing, undisclosed kickbacks, and outright fraud needed to protect workers and taxpayers.
Some background: OPM contracts with health insurance carriers to administer medical and drug benefits for over 8.2 million federal employees, dependents, and retirees. The costs of these benefits rose an average of 25.8% over the last two years, compared to 5.6% for overall inflation. The program is expected to cost about $80 billion in 2026, roughly twice as much as in 2018, with taxpayers picking up most of the tab.
Access to itemized claims data would allow OPM to reverse these runaway FEHB program costs. Right now, OPM flies blind. It receives only summary results from audits conducted by the Government Accountability Office and the Inspector General. It does not receive the underlying claims data itself.
The audits that do exist make a powerful case for why full data access matters:
- In March, the OIG audited the BCBS’s retail and mail-order pharmacy programs administered by CVS Caremark. Reviewing only a small sample of the hundreds of millions of claims processed over a multi-year period, auditors found that FEHB had been overcharged by $478 million on pharmacy claims alone.
- A separate GAO audit last year of claims processed by a BCBS affiliate identified 2,175 payment errors totaling nearly $1 million. Auditors also flagged problems related to network management, manual pricing, and settlement funds that were never remitted to FEHB.
- A 2025 OIG audit of Horizon Blue Cross and Blue Shield of New Jersey examined just 0.5% of the claims it processed and identified $10.8 million in net overcharges to FEHB and nearly $255,000 in overcharges to members. Findings included processing errors on out-of-network claims, coding and systems errors, and payments made for non-covered services. Horizon Blue Cross Blue Shield paid New Jersey $100 million to resolve improper payments higher than what was billed by providers.
- Another 2025 audit of BCBS of South Carolina found that FEHB claims were often paid at billed charges instead of lower negotiated rates.
Without knowledge of the exact amount providers billed and middlemen charged in fees, OPM can’t fix payment discrepancies. These are common occurrences. A recent State of Indiana report finds 79% of commercial claims from the Indiana All Payer Claims Database didn’t match actual prices. Moreover, OPM should be able to preaudit claims to stop overcharges and fraud before they occur.
Requesting this crucial data isn’t overreach. It’s basic oversight.
Author bio:
Cynthia A. Fisher is Founder and Chairman of PatientRightsAdvocate.org, a nonprofit organization seeking healthcare price transparency, giving power to American consumers and employers to lower their costs of care and coverage through a functional marketplace and choice. She is a life sciences entrepreneur, independent investor, and corporate board director of The Boston Beer Company (SAM) and Easterly Government Properties, Inc. (DEA).
Cynthia is best known for her pioneering work as Founder and CEO of ViaCord, Inc., a leading umbilical cord blood stem cell banking service which she started in 1993. In 2000, she co-founded and was President of the cellular medicines company, ViaCell, Inc. (VIAC). Cynthia holds an MBA from Harvard Business School, as well as an Honorary Doctorate of Science and BS in Biophysics from Ursinus College.
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