HEALTH · FRAUD PREVENTION
What Happened
As reported by Nextgov/FCW, CMS Deputy Administrator Kimberly Brandt stated fiscal year 2025 improper payments reached billions of dollars, with documentation errors among the biggest drivers. Brandt said CMS aims to use machine learning tools with providers, and that cutting documentation errors could reduce Medicare improper payment rates by up to two percentage points. CMS selected HealthEdge Software and Peraton to compete for a potential seven year ClaimsCore contract replacing four legacy systems, with Tegria providing implementation support.
Nextgov/FCW reported Brandt credited the Fraud Defense Operations Center, launched in March 2025, with stopping nearly $2.5 billion in suspect Medicare payments and acting against nearly 800 providers. A CMS fact sheet noted 2025 FDOC actions suspended over $1.8 billion across 249 providers, including over $1.5 billion in medical equipment and over $170 million in skin substitute billing.
Why It Matters
Prime contractors and contracting officers should prepare for real time fraud review and elastic scaling across modern claims processing systems.
What to Do Now
Vendors should align technical capabilities with ClaimsCore objectives, prioritizing automated documentation verification and real time payment tools.
WHERE XTAM FITS
Payment decisions in real time leave no room for wrong answers. XTAM builds high-trust AI and delivers it with embedded capabilities.