‘One CMS’ Strategy Aims to Modernize Operations, Combat Fraud

The Centers for Medicare and Medicaid Services is expanding its use of artificial intelligence to modernize healthcare operations, improve fraud detection and streamline services across Medicare, Medicaid and the federal insurance marketplace, agency officials said this week.

Speaking at the AFCEA Health IT Summit in Bethesda, Maryland, CMS leaders described how the agency is integrating AI tools into daily operations while modernizing legacy systems and improving interoperability across programs serving roughly 160 million Americans.

Officials said the effort reflects CMS’s broader “One CMS” strategy, which aims to better connect systems, data and offices across the agency while improving customer experience and reducing improper payments.

“CMS is a small agency with a huge mission and huge impact,” said Tiffany Swygert, acting deputy director of CMS’ IT office. “One thing that I’m seeing now from the OIT standpoint is that technology is really supporting the work that we do, no matter if you’re in CCSQ or CCIIO … we are all connected, and we are looking to support the enterprise. That’s really the name of the game now.” 

AI and Modernization at CMS 

Artificial intelligence has become a major focus across CMS operations, with officials describing it as both a workforce tool and a long-term strategy for improving healthcare delivery and data interoperability. 

Swygert said AI is already widely used inside the agency — with 80% of the workforce using it in daily operations — and they are looking at ways to integrate it into their services to create a more seamless experience for beneficiaries moving between systems.  

“We’re also looking at leveraging AI opportunities across the products that we deliver, so the three M’s as we like to call it: Medicare, Marketplace and Medicaid,” she said. “How can we serve all of those beneficiaries and make sure that we’re using the tools, so that when they come in … or if someone is moving from VA to Medicare, we want to have systems that are interoperable, and we can make sure that those things are connected.” 

The agency is simultaneously modernizing healthcare data systems. Mindy Riley, deputy group director of the Information Systems Group at CMS, said they have completed the conversion of electronic clinical quality measures into digital measures leveraging Fast Healthcare Interoperability Resources (FHIR). Beginning in 2027, new measure proposals submitted to CMS must include “a FHIR equivalent specification.” 

Consumer-facing systems are also undergoing upgrades. Beth Parish, acting deputy director for operations at the CMS Center for Consumer Information and Insurance Oversight, said CMS is continuing its ongoing effort that allows Healthcare.gov users to manage enrollment information and eligibility updates from a single interface.  

“At the same time, the needs keep changing. Our market is much more agent broker driven than it was five years ago or 10 years ago, and so we are working with external partners that create the systems that the agents work with to try to make sure that they have access to what they need. So as we work through the list and continue to update the list and chip away to create a better consumer experience, however that consumer is coming to us on Marketplace,” she said. 

Fraud Prevention 

Fraud prevention remains one of CMS’s most aggressive technology priorities, particularly as officials deploy AI and advanced analytics to identify fraudulent activity across federal healthcare programs. 

Bethany Messick, acting deputy director of the Data Analytics and Systems Group within the Center for Program Integrity, said CMS is shifting away “from pay and chase” response to a “stop and caught” response to fraud, meaning suspicious claims and enrollments are identified before payments are issued. 

“We’re really fortunate that technology really helps us get there. AI is really applicable to fraud identification and helping us move investigative work forward at a rapid pace, and we’re able to stop fraud much faster, even before the money goes out the door a lot of times,” Messick said. 

The agency’s Medicare Health Defense Operations Center brings together investigators, policy experts, legal counsel, data scientists and law enforcement to identify fraud schemes across Medicare. In its first year, the operation reviewed more than 300 providers and helped prevent over $2 billion in improper payments.  

CMS is looking to replicate those anti-fraud efforts in the Medicaid system, where Messick said there are similar schemes, if not more, because “the policy is a lot more unwieldy, because every state is different.”