The most significant messages learned from presentations at both the HCCA Compliance Institute and the National Provider Compliance Conference (NPCC) were not only that The Centers for Medicare and Medicaid Services (CMS) is using artificial intelligence or expanding fraud prevention efforts.
The bigger story is data fusion.
On June 30, 2025, as part of the Department of Justice’s National Health Care Fraud Takedown announcement, the federal government unveiled a new Health Care Fraud Data Fusion Center and described a broader “whole-of-government” approach to healthcare fraud enforcement. The initiative was designed to combine data, analytics, and investigative capabilities across agencies to identify suspicious patterns more quickly and intervene before improper payments occur. At the same time, CMS announced that it had prevented more than $4 billion in potentially fraudulent payments before they were issued
Historically, claims data, enrollment data, provider information, complaints, investigations, and other governmental datasets existed largely in separate silos. The message emerging from both conferences was that those silos are increasingly disappearing. When multiple datasets are analyzed together, anomalous billing patterns that might appear ordinary in isolation become much easier to identify.
This theme surfaced repeatedly in presentations from senior CMS officials at both conferences.
What This Means for Compliance Programs
The presentations suggest that healthcare providers should begin thinking beyond traditional claims audits.
Historically, compliance efforts focused heavily on:
- Documentation
- Coding accuracy
- Medical necessity
- Individual claim review
Those activities remain essential; however, the emerging environment increasingly evaluates organizations through multiple datasets simultaneously.
Compliance leaders should increasingly ask:
- Does our provider enrollment data match reality?
- Are ownership records current?
- Are credentialing records accurate?
- Do scheduling, documentation, and billing data align?
- Would multiple independent datasets tell a consistent story?
The most important compliance question may no longer be: “Can we defend this claim?”
Instead, it may be: “Would every available dataset support the same conclusion if regulators analyzed them together?”
Compass Healthcare Consulting’s Takeaway
After hearing directly from CMS leaders, including Kim Brandt, Amy Gleason, and Jennifer Dupree, and considering the federal government’s June 30, 2025 Data Fusion Center announcement, we believe that healthcare organizations are witnessing a significant transformation in federal healthcare oversight.
The convergence of:
- Data fusion
- Artificial intelligence
- Advanced analytics
- Real-time claims monitoring
- Claims platform modernization
- Interoperability
- Enhanced provider verification
- Expanded information sharing
- Aggressive administrative enforcement
is creating a program integrity environment unlike anything previously seen in Medicare and Medicaid oversight. Organizations that can monitor their own operations through this same enterprise-wide, data-driven lens will be best positioned for the next generation of healthcare compliance and enforcement.
The CMS Leaders Driving These Initiatives
Kim Brandt
Deputy Administrator and Chief Operating Officer
Centers for Medicare & Medicaid Services (CMS)
At HCCA, Kim Brandt described how CMS is approaching its role as the nation’s largest healthcare payer, overseeing nearly $2 trillion in annual healthcare spending and covering approximately half of the U.S. population through Medicare, Medicaid, and Marketplace programs.
Brandt’s presentation focused on:
- CMS as a leading payer and market influencer
- Value-based care expansion
- Program affordability
- Fraud, waste, and abuse reduction
- Real-time fraud prevention
- Claims modernization
- Artificial intelligence and advanced analytics
- Expanded law enforcement collaboration
- Public-private data sharing initiatives
Perhaps most importantly, Brandt emphasized that CMS is abandoning the traditional “pay and chase” model and moving toward what she described as prevention and detection before payment. She noted that CMS has significantly expanded its use of advanced analytics, machine learning, and cross-agency partnerships to identify suspicious activity much earlier in the payment cycle.
Amy Gleason
Acting Administrator, U.S. DOGE Service
Strategic Advisor to CMS
Amy Gleason’s presentation focused on technology modernization, but the implications extended far beyond interoperability and patient access.
Key initiatives included:
- The CMS Health Tech Ecosystem
- National Provider Directory development
- Provider identity verification
- Digital Medicare identity credentials
- Real-time interoperability
- Claims modernization
- Patient-controlled health information
- AI-enabled healthcare tools
Gleason described CMS’s effort to create a more connected healthcare infrastructure through improved identity management, provider directories, and data exchange networks. While often viewed as technology projects, these initiatives also create a stronger foundation for program integrity by improving provider verification, data quality, and operational transparency.
A recurring theme throughout her presentation was that healthcare oversight becomes more effective when CMS can trust the underlying data and accurately connect information across systems.
Jennifer Dupree
Deputy Director
Center for Program Integrity (CPI)
Centers for Medicare & Medicaid Services (CMS)
At NPCC, Jennifer Dupree provided perhaps the most direct view into how CMS is operationalizing these data-driven capabilities.
Her presentation focused heavily on:
- The Fraud Defense Operations Center (FDOC)
- The Medicaid Fraud War Room
- Artificial intelligence-driven fraud prevention
- Predictive analytics
- Enhanced Site Visits
- Enrollment moratoria
- Payment suspensions
- Provider revocations
- Public-private data sharing
- The Healthcare Fraud Prevention Partnership
- The CRUSH Fraud regulatory initiative
Dupree characterized CMS’s current strategy as moving from “Pay and Chase” to “Stop and Caught,” reflecting the agency’s desire to stop suspect payments before funds leave federal healthcare programs.
CMS reported substantial results from these efforts:
- More than $371 million in suspended Medicare payments
- More than 267 providers impacted
- More than 1,625 provider revocations
- More than $203 million in Medicaid savings through the Medicaid Fraud War Room
Artificial Intelligence Has Moved Into Production
One of the clearest themes across both conferences was that CMS no longer views AI as experimental technology.
CMS reported operating:
- 280 Fraud Prevention System models
- 83 Fraud Prevention System edits
- Predictive analytics programs
- Real-time fraud monitoring systems
- Automated claim intervention capabilities
CMS explained that these systems analyze incoming claims, identify suspicious billing patterns, and either refer providers for investigation or stop suspect claims during processing. The practical implication is that healthcare organizations should expect federal oversight to become:
- Faster
- More predictive
- More automated
- More data-driven
Data Sharing Is Expanding Rapidly
Another recurring theme was collaboration. CMS leaders discussed expanded cooperation among:
- CMS
- Department of Justice
- HHS Office of Inspector General
- State Medicaid agencies
- Medicaid Fraud Control Units
- Private insurers
- Supplemental payers
- Technology and analytics companies
CMS highlighted its participation in major DOJ fraud takedowns, expanded public reporting of provider revocations, information-sharing partnerships, and broader availability of payment suspension information to supplemental payers.
The consistent message was clear: More data is being connected, more partners are participating, and oversight is becoming increasingly integrated.
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