Alternative Headline: CMS Tackles Medicare Fraud Modernization
[MM Curator Summary]: CMS is modernizing its data systems – integrating clinical data using cloud analytics and metadate tools – to prevent Medicare fraud as new rules increase data complexity and risk.
====================================
Fraud, waste and abuse of the Medicare system have always been challenging to get under control. Although no precise measure of health care fraud exists, those who exploit federal health care programs can cost taxpayers billions of dollars, according to a Centers for Medicare and Medicaid Services report, while putting beneficiaries’ health and welfare at risk. The impact of these losses and risks magnifies as Medicare continues to serve a growing number of beneficiaries.
CMS’ Center for Program Integrity (CPI) plays a key role in managing this challenge by detecting, preventing and combating fraud, waste and abuse across CMS and other federal health programs. Beyond that, the organization is tasked with strengthening and expanding the scope of integrity programs, and integrating technological improvements like AI to reduce fraud, waste and abuse, and streamline operations.
In a time when efficiency has become top-of-mind for most agency and department heads, optimizing CPI’s ability to catch fraud, waste and abuse will play a key role in the federal government’s larger push to streamline operations and costs. The challenge is only getting bigger as CMS continues to modernize and reshuffle the way it handles patient data.
Meeting the needs of patients
To meet the expectations of patients and provide them with the value-based care experience they deserve, CMS is continually adapting its systems to mirror the greater healthcare industry. But doing that can create some hurdles in the fight against fraud, waste and abuse, including new interoperability rules that will fundamentally change the type of data coming into the agency.
In March, CMS finalized an interoperability rule to improve health information exchange and ensure patients’ access to their health records. While the new initiative, which goes into partial effect next year, is an important step toward creating a more efficient healthcare system, it requires CMS to ingest and merge a more diverse set of data than ever before. Formerly, CMS only dealt with administrative information like claims, but with the new streamlined process, the agency will also have to take in clinical data and account for all the new data classes that come along with it.
The reality of the situation is that once CMS starts bringing in data from hundreds of new partners there will be quality issues and a lot of noise. Put simply, when the aperture opens, there is a lot more opportunity for fraud. To combat this, CPI will need to lean on new technology that can sift and analyze this new massive influx of data.
Drilling down on data
Data management and analytics within the fraud, waste and abuse process will play a huge role in bolstering detection and prevention. Through cloud-based analytics platforms and a comprehensive data management plan, CPI will be able to gain actionable insights like identifying patterns related to how bad actors are defrauding CMS.
Technology has come a long way with analytics. It used to be that data management was limited to creating platforms for users. Now that has expanded to include enhancing data discoverability, supporting advanced analytic solutions and intertwining data quality within the data pipelines while securing the data in transit and at rest.
This all starts with establishing processes like a comprehensive collection mechanism for metadata at various stages of the data flow and developing tools to create a data discovery catalog. This leads to metadata visualization maps that can help CMS understand its data footprint. Without this kind of visibility, the agency will be flying blind as new data types and categories begin flowing in the next year. Once those steps are taken, CMS can continue to build that foundation. That means implementing a data quality framework and interlacing it with data pipelines to monitor the accuracy of data coming into the system.
Managing stakeholders and collaborators
Finding the people to help CMS and CPI in their journey is as important as the technology component. Stakeholder engagement and collaboration are key to successful program integrity. To that end, CMS needs to find the right partners to support fraud, waste and abuse detection and prevention.
Trusted partners that know CMS’ mission, problems and constraints are necessary for the successful implementation of next-generation data management solutions. Those with a history of fulfilling CMS needs will provide better cost-effective solutions as opposed to large data management solutions that are both costly and don’t tailor to the needs of the federal space.
Beyond that, CMS should seek out organizations with experience in solving an array of use cases for the federal government. A partner with experience in policy, analytics and technology will approach data management solutions with the intended goal of meeting the federal government’s mission.
In 2023, CMS spent $1.0298 trillion on Medicare and $871.7 billion on Medicaid. Medicare processes over one billion fee-for-service claims per year. Strengthening and enhancing fraud, waste and abuse activities will go a long way to making government operations more efficient and effective. Doing that won’t be easy, but the recommendations above will help level up CPI’s ability to root out these cases, allowing for a modernized CMS to serve patients more efficiently.
Michelle Atkins is vice president of program integrity services at RELI Group. Ken Hofgesang is vice president of health at RELI Group.
Copyright © 2025 Federal News Network. All rights reserved. This website is not intended for users located within the European Economic Area.
COLOR CODE:
General item, but important. Gets at main point of article= YELLOW
Has a dollar amount or number = GREEN
A specific topic that seems to be different than other topics = BLUE