CMS pitches new contractor operating model for 'detect and prevent' fraud strategy

The Centers for Medicare and Medicaid Services is exploring a new contract operating model and technologies to prevent fraud rather than chase money already paid to bad actors, according to documents posted on SAM.gov. Under the draft model, CMS would lead investigations while contractors review claims, conduct provider interviews and develop fraud leads using AI and analytics. The request for information closes Nov. 4.

• CMS wants a greater role in directing fraud investigations instead of just contracting them out
• Contractors could review claims, interview providers and develop leads from authorized data
• The RFI asks which AI, analytics and SQL methods CMS should use to detect fraud
• The Fraud Defense Operations Center has stopped nearly $2.5 billion in potentially fraudulent payments