A top CMS official wants provider suspensions to quadruple in the next six months as the agency puts new exclusion authority to work and tests AI tools to catch fraud, Nextgov/FCW reported Oct. 15.
CMS Deputy Administrator Kimberly Brandt discussed the agency’s enforcement efforts Oct. 15 at the ADAPT conference in Santa Fe, N.M. Ms. Brandt’s slideshow credited the anti-fraud effort with $41.9 billion in fiscal year 2025 savings, up 59% from the year before.
Her comments came after the Department of Health and Human Services delegated permissive exclusion authority under Section 1128(b) of the Social Security Act to CMS. The change, published Oct. 14 in the Federal Register, took effect immediately.
The authority allows CMS to exclude providers from Medicare, Medicaid, TRICARE and other federal healthcare programs. Previously, the agency did not have this formally delegated authority. She has said she pushed congressional offices to grant CMS the authority, according to Nextgov/FCW.
In April, CMS launched a Medicaid War Room to curb fraud, waste and abuse. Through September, the war room blocked $342 million in improper payments. It has also issued 124 notices of intent to exclude providers, the slideshow showed.
CMS is also using data matching to identify improper Affordable Care Act marketplace subsidies. The agency said Oct. 14 it identified 189,000 people with subsidized coverage through the federal marketplace who also had Medicare, Medicaid or Children’s Health Insurance Program coverage or were deceased. CMS said it removed the subsidies for those enrollees.
On the technology front, CMS is piloting AI and machine learning to detect Medicaid fraud. The pilots use AI to spot red flags such as upcoding, billing for phantom services and unusual geographic patterns, catching them before Medicaid pays the claims. CMS is also using the pilots to try out a joint workspace where CMS staff, states, law enforcement, Medicaid Fraud Control Units and program integrity contractors can coordinate on high-risk cases.
CMS’s goal, if the pilots work, is to expand them into a single nationwide system that stops fraudulent Medicaid claims before payment, according to the slideshow.
Results from an Indiana Medicaid fraud pilot CMS ran with Oracle will be released soon, Ms. Brandt said. The agency has Medicaid pilots underway with five more states.
Another technology initiative focuses on newly enrolled providers and suppliers. CMS is using an algorithm that compares new providers and suppliers with those the agency already works with. New providers and suppliers the algorithm flags face six months of added monitoring after joining a federal healthcare program. CMS has removed about 67% of them for not complying with program rules, Ms. Brandt said.
However, CMS has encountered challenges with some of its technology-driven initiatives.
Ms. Brandt acknowledged problems with the Wasteful and Inappropriate Service Reduction, or WISeR, model, which brings AI into prior authorization for Medicare items and services that CMS views as vulnerable to fraud.
“There are a lot of things about WISeR that are not working,” Ms. Brandt said.
Since the six-year model’s launch early this year, hospitals and Democratic lawmakers have argued it delays and denies care for seniors.
According to the slideshow, CMS’s takeaways from the model include the need for ongoing oversight of the technology, the importance of human clinical review and the value of provider feedback as a monitoring signal.
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