Last month, CMS convened a small, invitation-only group in New York City to tackle Medicare fraud. Nomi Health was one of roughly 40 experts invited to participate. The IDea Challenge brought together teams of experts and specialists to address increasingly sophisticated fraud schemes. Today's criminals don't just submit bad bills. They steal Medicare Beneficiary Identifiers, create synthetic identities, and exploit gaps in identity verification and payment security across the system.
Medicare fraud prevention policy doesn't stay in Washington. When CMS changes how it verifies identities and secures payments, commercial insurers and self-funded employer plans follow.
The goal of the session was a straightforward question: how do we reduce fraud without adding burdens to patients and providers?
Why Medicare Fraud Prevention Policy Matters for Self-Funded Employers
Medicare sets the standard. Policy changes start there, then move to commercial insurance. Self-funded employers, TPAs, and brokers should pay attention to this category of work because it signals direction: identity verification, payment integrity, and fraud prevention will move from back-office concerns to core requirements for healthcare financing.
"Essentially everything begins with Medicare in Washington, D.C.," says Ethan Jorgensen-Earp, Nomi's Vice President of Federal Government Affairs. "It's a trust-funded, highly utilized healthcare program. When you make a policy change, you start with Medicare and commercial insurance follows."
Key Themes from the CMS Medicare Fraud Prevention Session
Several themes emerged throughout the session:
- Reduce fraud without restricting legitimate access to care
- Identity threats evolve faster than security measures
- Stronger verification standards can reduce exposure across the system
- Solutions must work in real-world operations, not just in theory
"You could solve this problem the way credit card companies solved fraud," explained Brian Woods, who represented Nomi at the event. "But the rate-limiting step is this: how do we reduce fraud without putting pressure on beneficiaries and providers who are doing the right thing?"
Why CMS Invited Nomi Health to the Medicare Fraud Prevention Table
Nomi contributes experience across three areas that rarely sit together in one operating model:
1) Payment integrity and verification standards
Fraud prevention is ultimately a payments problem. Payment systems must verify transactions, ensure that all actors are legitimate, and stop suspicious activity, all without blocking valid care. Nomi's payment operations use the same rigorous verification standards that banks rely on, scaled for healthcare without creating provider friction.
2) Operational understanding of healthcare workflows
Security measures fail when they ignore real-world pressure: patients without cards, providers in a rush to verify eligibility, billing systems that don't talk to each other. Our systems work across these environments, so we can see exactly where patient identifiers circulate, where data becomes vulnerable, and where workflows fail under pressure.
3) Analytics at scale to detect emerging patterns
Fraud detection includes the ability to identify tactics early and to reduce false positives. Our work across large claim and payment datasets helps us determine which signals predict risk and which controls work in practice.
What Plan Sponsors and Self-Funded Employers Should Know
When CMS solves Medicare ID fraud without blocking care, those solutions will eventually shape how every payer handles member identification.
The work continues as CMS refines these solutions. We're committed to approaches that protect healthcare dollars without creating barriers to care.
Frequently Asked Questions
What is Medicare fraud and why does it cost $60 billion?
Medicare fraud occurs when bad actors exploit gaps in identity verification and payment security to steal from the system. Today's criminals steal Medicare Beneficiary Identifiers, create synthetic identities, and submit fraudulent claims at scale. The result: $60 billion in annual losses that drive up costs across the entire healthcare system.
How does Medicare fraud prevention policy affect self-funded employers?
Medicare sets the standard for the entire healthcare industry. When CMS changes how it verifies identities and secures payments, commercial insurers and self-funded employer plans follow. What happens in Washington today shapes how every payer handles member identification tomorrow.
What is the CMS IDea Challenge?
The IDea Challenge is an invitation-only session convened by CMS to bring together healthcare experts and specialists to tackle sophisticated Medicare fraud schemes. The goal: reduce fraud without adding burdens to patients and providers.
How does Nomi Health help prevent Medicare fraud?
Nomi brings three capabilities to fraud prevention: payment verification standards drawn from banking, operational knowledge of real-world healthcare workflows, and analytics that detect emerging fraud patterns across large claims datasets.
What should plan sponsors know about Medicare identity fraud?
Identity verification and payment integrity are moving from back-office concerns to core requirements for healthcare financing. Plan sponsors and TPAs who get ahead of these changes will be better positioned when they become standard practice across commercial insurance.
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