To detect fraud and ensure fair payments, CMS needed a trusted partner for reviewing thousands of complex medical claims each month, backed by expert clinical judgment and airtight processes.
The Challenge
Millions of Medicare and Medicaid claims are processed annually – and not all of them are paid accurately. The Centers for Medicare & Medicaid Services (CMS), through its Center for Program Integrity, needed a way to independently validate whether its contractors were reviewing claims accurately, in accordance with coverage rules, coding guidelines and payment policies.
This wasn’t about spot checks. It meant reviewing over 18,000 medical records each year – more than 1,500 each month – across dozens of specialties, including high-risk and high-volume services. The reviews required deep clinical expertise, fluency in coding rules, and the ability to spot both honest errors and red flags for potential fraud, waste, and abuse. CMS needed a partner who could manage the volume, protect sensitive health data, and deliver results with near-perfect internal accuracy.
Our Solution
Through the Medical Review Accuracy Contractor (MRAC) program, RELI Group supports CMS with comprehensive claim review services designed to hold contractors accountable and protect Medicare integrity. Our team of reviewers, including licensed clinicians and certified coders, evaluates each claim for compliance with federal policy, local coverage determinations and billing standards.
We don’t just review – we improve. Our team developed a multi-level quality assurance system to ensure precision, flag inconsistencies and identify opportunities to strengthen CMS guidance. We’ve also helped refine unclear policy language in the Program Integrity Manual, helping CMS clarify expectations, reduce misinterpretation and improve consistency across reviews.
Real Impact
Our reviews don’t just evaluate – they shape. We’ve performed nearly 100,000 claim reviews with over 99% internal QA accuracy, giving CMS confidence that Medicare claim decisions are being made correctly and consistently. We help CMS detect patterns of fraud, waste and abuse; identify where clarity is needed in policy; and ensure oversight mechanisms actually work.
Without this level of scrutiny, Medicare contractors could make payment errors unchecked, costing the government and taxpayers millions. With RELI’s support, CMS stays ahead of the problem, turning data into decisions and protecting the integrity of the healthcare system millions depend on.
