A top CMS official wants provider suspensions to quadruple in the next six months as part of a broader anti-fraud push that includes new exclusion authority and AI tools, 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.
“My hope is that suspension number will quadruple over the course of the next six months,” Ms. Brandt said, according to Nextgov/FCW.
Payment suspensions allow CMS to temporarily withhold some or all payments to a provider while suspected fraud or other payment concerns are investigated. Exclusions are a separate enforcement action that generally prohibits federal healthcare programs from paying for items or services furnished, ordered or prescribed by an excluded provider.
Separately, 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 under certain circumstances. Previously, the agency did not have this formally delegated authority. Ms. Brandt previously 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 identify suspicious billing patterns, including upcoding, billing for services that were never provided and unusual geographic patterns, before Medicaid payments are made. CMS is also testing a shared workspace where agency staff, states, law enforcement, Medicaid Fraud Control Units and program integrity contractors can coordinate on high-risk cases.
CMS’s goal, if the pilots prove successful, is to expand them into a nationwide system designed to stop fraudulent Medicaid claims before payment, according to the slideshow.
Results from an Indiana Medicaid fraud pilot CMS conducted with Oracle will be released soon, Ms. Brandt said. The agency has Medicaid pilots underway with five other 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. Those flagged by the algorithm are placed on a watchlist for their first six months in a federal healthcare program. CMS has removed about 67% of those flagged providers and suppliers for failing to comply 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 uses AI-supported prior authorization for Medicare items and services CMS considers vulnerable to fraud.
“There are a lot of things about WISeR that are not working,” Ms. Brandt said.
Since the six-year model launched earlier this year, hospitals and Democratic lawmakers have criticized it, arguing that it delays or 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.
Editor’s note: Becker’s has contacted CMS for clarification on the scope of the agency’s provider suspension target and how it relates to the newly delegated exclusion authority. This article will be updated if a response is received.
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