CMS Requests Feedback on New Fraud Detection Contractor Model

On October 5, 2026, the Centers for Medicare & Medicaid Services (CMS) launched a Request for Information (RFI) seeking industry feedback on a proposed outcome-focused contractor operating model designed to improve fraud detection and prevention across various federal healthcare programs. This initiative builds upon previous efforts aimed at addressing fraud, waste, and abuse, indicating a shift towards a more proactive approach in combating these issues, rather than reacting to fraud once it occurs.

Historically, CMS contracted with private entities to enhance its capabilities in investigations and administrative actions. However, the agency acknowledges that the existing models might not be sufficient given advancements in technology and methodologies available today. According to Kimberly Brandt, a CMS Deputy Administrator, the old model “worked in the past but new technology and new techniques mean it is time to see if it still works as well.” The proposed contractor model aims to delineate the responsibilities more clearly, emphasizing a central overseeing role for CMS while contractors will execute operational functions such as claims analysis, investigations, and medical reviews under CMS supervision.

The draft operating model represents a significant shift in governance and strategy. CMS intends for contractors to take on a more defined role in fraud investigations, thereby increasing accountability and effectiveness in addressing fraud-related issues. The new approach will also allow contractors to exploit potential fraud leads from authorized data sources, subject to CMS's approval. Such changes not only aim to bolster operational efficiencies but also call for collaboration across various program integrity stakeholders, which may include interagency coordination.

The RFI poses critical questions for contractors regarding the best methodologies for fulfilling these proposed roles. For instance, CMS is interested in understanding the advantages and disadvantages of centralizing compliance-related tasks and how it might affect provider site verifications. Moreover, the agency seeks insights on whether contracting with specialized companies for various provider types would be more beneficial. Importantly, these inquiries signal that CMS is leveraging industry expertise to fine-tune its operational strategies and ensure that engagements align with technological innovations.

However, the RFI has presented a notable issue: conflicting deadlines for submissions. Initially, it was indicated that responses are due by November 4, 2026, at 11 a.m. ET, but there is also a later date of November 27, 2026 mentioned in some communications. This discrepancy necessitates that interested organizations double-check the official RFI to confirm accurate deadlines, ensuring that their valuable insights are submitted punctually.

This move by CMS is not just a minor adjustment; rather, it signifies an operational evolution in how federal healthcare programs address fraud and misconduct. As such, it opens opportunities for contractors specializing in program integrity, claims analytics, AI technologies, and investigative services. While this RFI is currently for market research purposes and does not translate to immediate contract awards, it serves as an indicator of future requirements and potential pathways for involvement in CMS projects.