- Access to federally protected data is complex and time-consuming.
a) CMS data environments allow authorized users to access CMS datasets under datasharing agreements and to perform analyses across those datasets. However, gaining access is a multi-step process that can take several weeks, beginning with the approval of a data use agreement. Additional requirements include completing business and technical training (e.g., database and BI tools), configuring VPN access on local computers, and navigating agency-specific procedures. Timely progress depends on support from internal CMS resources and clear, open communication channels to resolve issues efficiently.
b) Early decisions about the data access and analysis environment are critical. Any environment used to access federal data must comply with federal cybersecurity and data security requirements. The team learned that access to a secure agency environment could have been expedited if an interagency agreement had been established before the project launch.
- A narrow analytical focus is essential for short-duration projects.
Given the project’s limited timeframe, it was critical to work closely with the Department of Justice’s Fraud team to focus on one or two related types of fraud that are both high-risk and feasible within existing data and system constraints. The following factors guided the selection of the project’s focus:
- Data availability, accessibility, and usefulness
- Likelihood of fraud based on known or similar cases
- Care setting
- Billing or business practices
- Provider type
- Geographic location
- Careful definition of key variables is foundational to AI/ML-based fraud detection.
During the first quarter, Cormac focused on identifying the data elements and contextual information most likely to indicate fraudulent activity, as well as the analytical processes and tools needed to flag suspicious patterns. The team also considered the required outputs and how results should be communicated clearly, including in plain language, to support effective interpretation and use.
