With over 200,000 providers in alternative payment models, CMS needed a smarter way to spot risk early and ensure Medicare dollars were spent the right way.
The Challenge
The Center for Medicare & Medicaid’s (CMS’) Innovation Center (CMMI) is driving major changes in how healthcare is paid for – shifting away from fee-for-service toward value-based models that reward outcomes over volume. But with innovation comes complexity. Over 250 alternative payment model (APM) entities, more than 2,000 primary care practices, and 200,000+ providers participate across models like ACO REACH, Primary Care First, Kidney Care Choices and ESRD Treatment Choices.
To safeguard Medicare beneficiaries and the Medicare Trust Fund, CMS needed a rigorous system for monitoring compliance, auditing activity, and detecting fraud, waste and abuse (FWA) across this sprawling network. The challenge wasn’t just scale – it was designing risk-based approaches that could proactively identify issues before they became costly problems.
Our Solution
Through the Compliance Support for Multiple Models (CSMM) contract, RELI Group delivers comprehensive oversight across four of CMS’ highest-impact payment models. We support every phase of compliance, monitoring, auditing and vetting for participants – helping CMS manage risk at scale.
Our work begins with a risk-based monitoring framework designed to surface early signs of noncompliance or potential fraud, waste and abuse. We conduct targeted audits and detailed vetting of provider performance, ensuring alignment with CMS policies and model-specific requirements. At the same time, we develop and implement predictive modeling strategies to proactively identify FWA triggers – allowing CMS to act before issues escalate. Across every touchpoint, we translate complex data into actionable insights, equipping CMS with the tools to intervene quickly and enforce corrective actions where needed.
This holistic, forward-looking approach allows CMS to safeguard Medicare funding, protect beneficiaries, and maintain the integrity of its most ambitious care delivery models.
Real Impact
With RELI’s support, CMS is able to oversee more than a million beneficiaries participating in innovative care models – all while maintaining the guardrails that ensure trust, transparency and accountability.
We help CMS stay ahead of risk, not just react to it. And by surfacing compliance issues early, our efforts drive improvements that ripple across the entire healthcare system – ultimately helping providers deliver better care at a lower cost.
Without this work, CMS would lose visibility into some of its most ambitious payment reform initiatives – opening the door to unchecked FWA and weakening the integrity of programs designed to deliver better outcomes for patients. RELI helps ensure these models live up to their promise.
