Identifying Fraud Threats in Medicare and Medicaid

Medicare and Medicaid are large, complex programs that process enormous volumes of claims, deliver services to millions of beneficiaries, and interact with a vast network of healthcare providers. As payment policies, coverage rules, and enrollment requirements evolve, new opportunities for fraud, waste, and abuse can emerge. Identifying these threats is challenging because fraud schemes often exploit subtle vulnerabilities and may remain hidden until significant losses have already occurred. CMS therefore needs effective ways to detect emerging risks, understand potential exposure, and intervene before small issues become larger program integrity concerns.

Emendata helps CMS identify and address potential vulnerabilities before they lead to significant program losses for Medicare or Medicaid. In addition to proactively assessing how payment policies, enrollment processes, and program operations may create opportunities for abuse, our team applies advanced analytical techniques, including machine learning, to identify anomalous patterns in claims, enrollment, and other program data. We quantify potential exposure, support the development of preventive controls, and help inform the use of administrative actions. By combining quantitative analysis with deep policy and investigative expertise, we help CMS uncover potential fraud schemes, understand their root causes, and develop effective responses.

The resulting analyses produced a steady pipeline of actionable leads for further investigation and informed administrative actions to address identified risks. Findings were also used to inform program integrity policy, support major fraud-fighting initiatives, and collaborate with law enforcement. Together, these activities helped CMS move from identifying vulnerabilities to implementing actions that protect Medicare and Medicaid from fraud, waste, and abuse.