CMS Deputy Administrator Testifies Before Congress on Fraud
Kim Brandt, Deputy Administrator & Chief Operating Officer for the Centers for Medicare & Medicaid Services (CMS), last month provided testimony to the Oversight and Investigations Subcommittee of the House Energy and Commerce Committee (O&I/E&C) addressing the role of CMS in combating Medicare and Medicaid fraud.
Brandt characterized the CMS approach to fraud oversight as “moving from a ‘pay and chase’ strategy to a ‘caught and stopped’ approach.” She described the Fraud Defense Operations Center (FDOC), which “integrates cross-functional expertise through a specialized team of data analysts, investigators, health policy experts, legal advisors, and law enforcement,” and state visits that have “focused on data sharing, joint enforcement strategies, and using state tax investigations as a faster pathway to hold fraudulent providers accountable.”
Brandt also shared overall strategies that CMS is focused on in both Medicare and Medicaid, including:
- collaboration with law enforcement and federal agencies, such as “the use of advanced data analytics and interagency collaboration to identify, investigate, and prosecute fraudulent health care providers, shifting the focus to deterrence, recovery, and appropriate criminal sanctions for fraudulent actors;”
- enhanced provider screening in Medicare and, in Medicaid, use of the Data Exchange (DEX) system to facilitate “the sharing of provider termination and revocation data among CMS and state programs, maintaining a centralized repository accessed by all 50 states, the District of Columbia, and Puerto Rico;”
- leveraging technology and data integration “by linking Medicare and Medicaid claims data, provider ownership information, pharmacy records, and external data sources” and utilizing AI and machine learning tools to enhance anomaly detection;
- increased scrutiny on Medicaid eligibility and enrollment processes such as requiring states to “conduct interstate matching via the Public Assistance Reporting Information System (PARIS) to confirm that beneficiaries are not enrolled in Medicaid or CHIP programs across multiple states” and, beginning in 2027 as mandated by HR 1, requiring states to “check the Social Security Administration’s Death Master File (DMF) on at least a quarterly basis to identify any Medicaid enrollees who are deceased;” and
- “analyzing claims data, billing patterns, provider characteristics, geographic trends, and prior enforcement history [to identify] service lines, provider types, or regions that present elevated risk of improper payments or beneficiary harm,” allowing the agency to “apply enhanced screening, prepayment review, prior authorization, or focused audits to high-risk areas rather than burdening all providers with unnecessary oversight.”
CMS will be joining us at the June Symposium to discuss their approach to recent policy and focus shifts including fraud and program integrity.
FMI: Read the testimony at THIS LINK.