"FDOC brings together a whole bunch of people to take a look in real time at data as claims are getting submitted, allowing CMS to detect spikes or aberrancies in current claim submissions by utilizing input from a cross-dimensional team of personnel that includes data analysts, fraud investigators, lawyers and clinicians."
"Through the work of the FDOC and its use of AI tools and enhanced data analysis to drive its efforts, CMS has been able to save over $2 billion that would have otherwise gone toward improper payments, with particular success resulting in a 99% decrease in billing for skin substitutes."
"The agency is moving toward prevent and detect, versus the pay and chase model when it comes to stopping improper payments before they are even made, representing a fundamental shift in how CMS approaches fraud prevention and detection across its operations."
The Centers for Medicare and Medicaid Services is expanding its technology-driven efforts to combat waste, fraud, and abuse across its operations. The agency's Fraud Defense Operations Center, launched in March 2025, represents a shift from reactive "pay and chase" models to proactive prevention and detection of improper payments. This unit brings together data analysts, fraud investigators, lawyers, and clinicians to monitor claims in real time using AI tools and enhanced data analysis. The collaborative approach has generated over $2 billion in savings, including a 99% reduction in billing for skin substitutes where abnormally high levels were previously detected. CMS plans to intensify these efforts further, particularly by examining the Medicaid system more closely.
Read at Nextgov.com
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