The Program-Integrity Market Just Moved Upstream

The Tuesday public issue named the design failure. This Capture Corner is the part of the analysis your competitors cannot reach without doing the work you have already done by being a subscriber.

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Companion to "The Fraud Was in the Workflow." Action windows, confidence labels, named signals, and the capture spine for the next twelve months of federal healthcare program-integrity work.

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How This Connects to the Public Issue

The Tuesday Special Report named the design failure. The Pivot Shift test is the line everyone will remember. This Capture Corner is the part of the analysis your competitors cannot reach without doing the work you have already done by being a subscriber.

The mental model the public piece left readers with: fraud does not begin at the claim. It begins where lead generation, documentation, clinician identity, templates, and payment rules meet.

That sentence is the capture spine. Every federal procurement, RFI, and demonstration moving right now is pulling the program-integrity market upstream from the claim toward the workflow. The vendors that will win this market over the next twelve months are the ones that build offerings around that shift. The vendors that lose are the ones still selling "AI fraud detection" as a generic analytics product.

This issue gives you the named signals, the buyer map, the language to use and avoid, the live action windows, and the specific URLs to monitor this week.

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What Just Changed: The May 13 Moratorium

Confidence: HIGH. Source: CMS press release, Federal Register notices, CMS PECOS enrollment moratoria page.

On May 13, 2026, four days before this issue publishes, CMS implemented a temporary nationwide enrollment moratorium on Home Health Agencies (HHAs) and Hospices. The Federal Register notices published May 15, 2026 are 2026-09717 (HHA) and 2026-09718 (Hospice). [1] [2] [3] [4]

The moratorium applies to initial Medicare enrollment applications and to non-exempt changes in majority ownership under 42 CFR 424.550(b). It runs for six months and can be extended in six-month increments. Applications submitted after May 13 will be denied. Existing providers are not affected. This follows the February 27, 2026 nationwide moratorium on certain DMEPOS medical supply companies. [4]

The moratorium was announced in coordination with Vice President Vance's Anti-Fraud Task Force. DOJ is a named member of that task force under the March executive order, and DOJ's April fraud-enforcement actions show the same whole-of-government fraud posture moving into healthcare program integrity. CMS Administrator Dr. Mehmet Oz framed the moratorium around "shutting the door on fraud" while ongoing investigations continue. CMS has already suspended approximately $70 million in payments to 773 hospices and 23 home health agencies suspected of fraud in Los Angeles. [5] [6]

The operational detail most coverage missed. CMS named six states for heightened oversight of newly enrolled Medicare hospice providers: Arizona, California, Georgia, Ohio, Nevada, and Texas. CMS also expanded a pre- and post-claim review demonstration to Florida, Illinois, Oklahoma, Ohio, North Carolina, and Texas. Enhanced enrollment screening for high-risk HHAs now includes site verification of reported practice locations and fingerprinting-based background checks. A publicly available hospice scoring system is also coming. [1]

Capture translation: these are six concurrent procurement and demonstration surfaces. Identity proofing. Site verification. Background-check workflow. Pre- and post-claim review tooling. Ownership graphing. Provider scoring. Each one is a buy or a contract modification within the next 12 to 18 months. Build a teaming sheet now for each of the six and start mapping incumbent positions.

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The Capture Spine

Confidence: HIGH. Spine derived from the architecture argument in the public piece and corroborated by every named procurement signal below.

The market is buying workflow assurance, not generic AI fraud detection.

That is the entire spine. Every offer, capability statement, white paper, and demo for the next twelve months in federal healthcare program integrity should be built around four words: verify the workflow before payment.

Use this language:

• We help agencies verify the workflow before they pay the claim.
• Our system preserves encounter provenance, template history, clinician identity, human-review decisions, and payer-submission paths in one auditable chain.
• We reduce fraud without reducing access by separating legitimate telehealth from order-factory behavior.
• Our offering brings the documentation surface into compliance with CMS program-integrity controls without burdening legitimate clinicians.

Avoid this language:

• We use AI to deny improper claims.
• Our model catches fraud automatically.
• We replace reviewers with AI.
• Black-box risk scoring.

The first list speaks the language CMS, OIG, DOJ, and the WISeR participants are already using. The second list reads to a senior program-integrity buyer the way a vendor sounded in 2018. Procurement officers can tell the difference within thirty seconds of a capability briefing.

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The Six Capture Lanes

Each lane below names what the federal customer is buying, the confidence level on the signal, the named procurement or demonstration surface, and where capture teams should focus.

Lane 1: Encounter and Order Provenance

Confidence: HIGH. Source: HealthSplash superseding indictment, public Tuesday issue framework.

Every reimbursable order should carry structured proof of who requested it, who reviewed it, how the encounter occurred, what evidence supported it, which template generated it, and whether AI assisted the documentation. The HealthSplash case made this the most defensible capture pitch in the market because it gave federal buyers a concrete failure mode to point to.

Best capture targets: vendors that can integrate identity, clinical documentation, telehealth metadata, e-signature controls, and immutable audit logs. Teaming opportunities with EHR vendors, telehealth platforms, and identity-proofing providers.

Action item: build a one-page reference architecture diagram showing how your offering captures the ten provenance fields named in the public issue. Lead every capability briefing with that diagram.

Lane 2: Identity, Ownership, and Enrollment Integrity

Confidence: HIGH. Source: CMS PECOS enrollment moratoria page, May 13 press release.

The moratorium makes ownership visibility and enrollment integrity a front-door priority. The change-in-majority-ownership angle is especially important. CMS specifically flagged ownership changes used to obscure control by bad actors.

Best capture targets: identity proofing, beneficial ownership mapping, related-party detection, address reuse analytics, NPI/PTAN relationship graphs, and re-entry detection after revocation. Teaming opportunities with credit-bureau identity providers, KYC/AML adjacencies, and corporate registry data vendors.

Action item: map every state where CMS named elevated fraud risk (AZ, CA, GA, OH, NV, TX) against your existing state Medicaid program-integrity relationships. The state work is now a more aggressive sales motion because CMS is using the federal moratorium to push parallel state moratoria. Ropes & Gray confirmed CMS is deferring to state Medicaid agencies on whether to implement comparable state-level moratoria. [7]

Lane 3: Graph Analytics and Entity Resolution

Confidence: HIGH. Source: Pattern across Operation Brace Yourself, LabSolutions, the 2022 telemedicine takedown, the April 2026 hospice takedown, and DOJ's West Coast Strike Force language.

The schemes named in the public piece are networks, not isolated claims. The capture language that wins reflects that: connect beneficiary brokers, call centers, telemedicine entities, suppliers, labs, hospices, billing companies, owners, addresses, NPIs, bank accounts, and clinicians into one risk graph. Anomaly detection sees a symptom. The graph sees the network.

Best capture targets: graph database vendors, entity-resolution specialists, link-analysis tools used by federal law enforcement. Teaming opportunities with the FBI, DEA, OIG, and DOJ enforcement-support contractor base.

Action item: if your offering does not produce a visual graph output a non-technical investigator can read, build one before your next briefing.

Lane 4: Medical-Review Workflow Modernization

Confidence: HIGH. Source: CMS WISeR Provider and Supplier Guide, SMRC RFI activity.

WISeR shows that review speed and clinical defensibility are both buying criteria. Standard prior authorization decisions are due in 3 calendar days, expedited decisions in 2 calendar days, and human clinician review is required before non-affirmation determinations. The six named WISeR participants are Cohere Health (Texas), Genzeon (New Jersey), Humata Health (Oklahoma), Innovaccer (Ohio), Virtix Health (Washington), and Zyter (Arizona). The model runs from January 1, 2026 through December 31, 2031 and covers high-risk service categories including knee arthroscopy, nerve stimulation, incontinence devices, vertebral augmentation, epidural steroid injections, cervical fusion, hypoglossal nerve stimulation, and skin substitutes. [8] [9]

Best capture targets: intake automation, triage, documentation completeness checks, clinical-criteria mapping, human-review queues, provider communication, UTN tracking, appeal packets, and defensible rationale generation. SDVOSB and 8(a) capture teams should target subcontract positions on review workflow tooling. SMRC-scale contracts do not typically award to small business primes, but the documentation intake, clinical-criteria mapping, and rationale-generation components are addressable through teaming arrangements with the prime.

Action item on SMRC: the SMRC RFI (RFI-CMS-SMRC-2026-001) closed April 23, 2026. The actual solicitation is the next surface to watch. The current SMRC is Noridian Healthcare Solutions, per the CMS SMRC program page. Capture teams should be monitoring SAM.gov and the CMS Office of Acquisition and Grants Management for the formal solicitation now. The RFI named medical review, program-integrity reviews, claims re-reviews, data analysis, ALJ defense, home health, and statistical extrapolation. [10] [11]

Lane 5: Explainable AI and Model Governance

Confidence: HIGH. Source: CMS Milliman glass-box AI selection, AMA deepfake-doctor policy, federal AI executive orders.

Program-integrity AI will face provider pushback. Vendors who cannot explain why a request was flagged or denied will lose to vendors who can. Strong offers should include model cards, audit trails, clinician override capture, bias monitoring, coverage-criteria traceability, and false-positive governance.

Best capture targets: explainable AI platforms, model governance tools, audit-log preservation systems, and clinician-feedback capture. Teaming opportunities with EHR vendors and clinical decision support platforms.

Action item: if your offering currently produces a single risk score with no rationale text, build the rationale layer before your next demo. The Milliman glass-box framing is now the bar.

Lane 6: Enforcement-Support Analytics

Confidence: HIGH. Source: DOJ National Fraud Enforcement Division, West Coast Strike Force, FOCUS initiative announcements.

DOJ's strike force language points to demand for case-ready intelligence rather than dashboards. Vendors should sell packages that convert raw anomalies into investigative leads, relationship maps, scheme typologies, loss estimates, referral narratives, and evidence bundles for HHS-OIG, DOJ, FBI, DEA, and state partners.

Best capture targets: investigative case management, prosecutorial evidence assembly, statistical extrapolation, and qui tam relator support tools. Teaming opportunities with former AUSA-led consulting shops and forensic accounting firms.

Action item: map your offering to DOJ's named target categories. The West Coast Strike Force specifically named digital health technology fraud, Medicaid fraud, sober home fraud, wound care/wound graft fraud, technology-driven schemes, controlled-substance diversion, and TRICARE-related billing. Each is a separate capture lane with separate procurement surfaces. The FOCUS initiative is specifically designed to strengthen DOJ's relationship with data-miners filing qui tam complaints. That is a market signal to qui tam relator support tools as much as it is an enforcement signal. [12] [13] [14]

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Named Market Signals Table

Signal	Date	Source	Confidence	Capture relevance
CMS HHA/Hospice enrollment moratorium	May 13, 2026	CMS press release; Fed Reg 2026-09717, 2026-09718	HIGH	Lanes 2, 3, 4
CMS hospice scoring system (coming)	Announced May 13, 2026	CMS press release	HIGH	Lane 5
Enhanced HHA screening: site verification + fingerprinting	May 13, 2026	CMS press release	HIGH	Lanes 2, 4
Pre/post-claim review demo expansion (FL, IL, OK, OH, NC, TX)	May 13, 2026	CMS press release	HIGH	Lane 4
DMEPOS enrollment moratorium	February 27, 2026	CMS PECOS page	HIGH	Lanes 2, 4
WISeR pilot (6 states, 6 participants, 2026-2031)	January 1, 2026	CMS WISeR Provider Guide	HIGH	Lanes 4, 5
SMRC RFI (closed April 23, 2026)	April 14, 2026	CMS Office of Acquisition and Grants Management; SAM.gov	HIGH	Lane 4
DOJ National Fraud Enforcement Division	April 2026	DOJ press release	HIGH	Lane 6
DOJ West Coast Strike Force	April 30, 2026	DOJ press release	HIGH	Lane 6
DOJ FOCUS initiative (qui tam data-miner partnership)	2026	DOJ press release	HIGH	Lane 6
LA payment suspensions: 773 hospices, 23 HHAs, ~$70M	May 13, 2026	CMS press release, STAT News	HIGH	Lanes 3, 6
CMS FY2025 program-integrity savings: $41.9B (ROI $22.3:$1)	2026	CMS fraud page	HIGH	All lanes: the budget signal
Revoked Medicare Providers and Suppliers dataset	Live	CMS fraud page	MEDIUM	Lanes 2, 3

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Buyer Map

Buyer or influencer	What they need now	Capture angle
CMS Center for Program Integrity	Earlier detection, prevention, analytics, enrollment integrity, contractor oversight	Sell workflow assurance across provider enrollment, claims, medical review, ownership, and payment controls
CMMI / WISeR ecosystem	AI-assisted review with human clinician validation and fast turnaround	Sell clinical-review orchestration, evidence capture, audit logs, and model governance
Medicare Administrative Contractors (MACs) and review contractors	Work tracking, documentation intake, UTN handling, medical review support, appeal defense	Sell document intelligence, review workflow, provider burden reduction, explainable determinations
Unified Program Integrity Contractors (UPICs)	Cross-jurisdiction fraud investigation, referral assembly	Sell graph analytics, entity resolution, evidence assembly
SMRC (currently Noridian; recompete in progress)	National medical review, statistical extrapolation, ALJ defense	Sell intake, triage, clinical criteria mapping, extrapolation tooling
HHS-OIG / DOJ / FBI / DEA	Cross-entity intelligence, scheme migration detection, enforcement packages	Sell graph analytics, entity resolution, case-ready intelligence, referral-quality case files
VA / DHA / TRICARE program offices	Digital health fraud resilience without weakening access	Sell clinician identity protection, telehealth encounter provenance, network-level anomaly detection. Note: West Coast Strike Force named TRICARE-related billing as a target category.
State Medicaid program-integrity units	Provider screening, ownership visibility, cross-state fraud migration detection	Sell cross-program identity matching, ownership graphing, risk scoring. The May 13 moratorium creates parallel state-level moratoria opportunities.

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What to Watch This Week

These are the specific URLs Founding Members should bookmark and check this week. None of them are state-of-the-art research. They are operational pages where the next round of federal program-integrity signals will land.

Surface	URL	What to watch for
CMS fraud page	cms.gov/fraud	New program-integrity announcements, dashboard launches, dataset releases
CMS provider enrollment moratoria	cms.gov/medicare/enrollment-renewal/providers-suppliers/chain-ownership-system-pecos/provider-enrollment-moratoria	Moratorium extensions, new categories, FAQ updates
CMS WISeR model	cms.gov/priorities/innovation/innovation-models/wiser	Year-1 evaluation data, expansion announcements, participant additions
Federal Register	federalregister.gov	Moratorium extensions (next decision point: approximately November 13, 2026 if not extended earlier)
SAM.gov	sam.gov	SMRC follow-on solicitation, any related program-integrity opportunities
DOJ Office of Public Affairs	justice.gov/opa	Strike force expansion announcements, FCA settlements
HHS-OIG news	oig.hhs.gov	New Special Fraud Alerts, work plan updates, exclusion list announcements

One-time check this week: review the CMS Hospice and Home Health Moratorium FAQ (cms.gov/files/document/hh-hospice-moratorium-faqs.pdf) for any operational detail your offering can speak to in the next capability briefing. The FAQ is the canonical source CMS will refer back to in every subsequent statement on the moratorium.

DHA and TRICARE implications. The DHA and TRICARE program-integrity surface is moving in parallel with CMS. A future Capture Corner will translate this analysis into specific DHA and TRICARE acquisition windows for the MMT readers focused on the defense health enterprise.

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Action Windows

Next 30 Days (by mid-June 2026)

Build the workflow-assurance one-page reference architecture. Map your current offering against the ten provenance fields named in the public Tuesday issue and against the six capture lanes above. Identify the two lanes where you have the strongest current position. Build a one-page capability brief specifically for those two lanes. Stop sending generic "AI fraud detection" decks.

Monitor for the SMRC follow-on solicitation. The RFI closed April 23, 2026. CMS solicitations on contracts of this size typically follow within 60 to 120 days of RFI close. MMT projection only: expected solicitation drop window is late June through early August 2026. CMS has not committed to a public timeline.

Confirm whether your current offering captures all six elements of the enhanced HHA enrollment screening: site verification, fingerprinting-based background check, and the implied identity and ownership graphing capabilities.

Next 60 Days (by mid-July 2026)

Map teaming targets around the six WISeR participants, the MAC base, UPICs, the SMRC competition, Medicaid program-integrity contractors, and enforcement-support vendors. The teaming map should answer three questions. Who has the contract vehicle and the past-performance reference. Who has the technology you do not. Who has the customer relationship you do not.

Prepare three use case briefs: one for DME, one for hospice/home health, and one for telehealth prescribing. Each should walk through the same workflow-assurance reference architecture and show how it applies to that specific fraud surface. The use case briefs are the deliverable that wins the second meeting after a successful first capability briefing.

Next 90 Days (by mid-August 2026)

Package a demo that starts with a suspicious order, not a suspicious claim. The demo should show, in this order: lead-source risk, encounter provenance, clinician identity verification, template history, ownership graph, medical-necessity evidence, human-review decisioning, and referral-ready case assembly. That demo is the procurement-conversation pivot point. Based on what MMT has seen across the program-integrity vendor base this year, very few vendors are delivering this end-to-end.

Begin pre-positioning for additional regional strike forces. The West Coast precedent makes additional regional strike forces a reasonable analytical projection. Capture teams positioned in DC, Atlanta, Houston, and Miami should be having pipeline conversations with US Attorney's Offices and OIG regional leadership in those metros now.

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Capture Questions to Ask Now

Each question below is designed to surface the gap between what the federal program-integrity buyer is buying today and what they actually need.

1. What proof does the agency require that a reimbursable order came from a legitimate encounter?

2. Which data elements are captured before payment, and which only appear after the claim?

3. Can the buyer connect ownership, enrollment, claims, encounter, and contractor-review data in one graph?

4. How are telehealth modality, encounter duration, lead source, template version, and clinical basis preserved?

5. What is the handoff from anomaly detection to medical review, payment suspension, investigation, or referral?

6. How does the agency measure provider burden, false positives, appeal reversals, and access impact?

7. What evidence package would HHS-OIG or DOJ need if a flagged pattern became an enforcement referral?

8. How does the agency plan to integrate AI-assisted documentation governance with its existing fraud-detection AI? Almost no vendor is asking that question. Almost no buyer has answered it.

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The Premium Bottom Line

The companies that will win the next twelve months of federal healthcare program-integrity contracts will speak the language of access, evidence, identity, provenance, and human review. They will arrive at the capability briefing with a workflow-assurance reference architecture, a one-page graph that the procurement officer can read in thirty seconds, and a demo that starts with a suspicious order, not a suspicious claim.

The companies that will lose will keep pitching "AI fraud detection" as if CMS and DOJ had not already moved on.

The simplest version of the spine is the line from the public issue:

No reimbursable order should be easier to fake than to verify.

That is the procurement requirement. That is the engineering requirement. That is the readiness requirement. It is also the capture spine for every conversation you have with a federal program-integrity buyer between now and the next federal fiscal year.

The work is in front of you. Build accordingly.

Let's roll.

— Mary

Mission Meets Tech

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The views expressed in this Premium issue are my own and do not represent the official position of any organization. This content is for informational and capture-planning purposes only and is not legal, procurement, or investment advice.

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Sources

[1] Centers for Medicare and Medicaid Services, "CMS Announces Aggressive Nationwide Crackdown on Fraud with Six-Month Hospice and Home Health Agency Enrollment Moratoria," May 13, 2026, https://www.cms.gov/newsroom/press-releases/cms-announces-aggressive-nationwide-crackdown-fraud-six-month-hospice-home-health-agency-enrollment.

[2] Federal Register, "Medicare, Medicaid, and Children's Health Insurance Programs: Announcement of Nationwide Temporary Moratoria on Enrollment of Home Health Agencies (HHAs)," 91 Fed. Reg., May 15, 2026, https://www.federalregister.gov/d/2026-09717.

[3] Federal Register, "Medicare, Medicaid, and Children's Health Insurance Programs: Announcement of Nationwide Temporary Moratorium on Enrollment of Hospices," 91 Fed. Reg., May 15, 2026, https://www.federalregister.gov/d/2026-09718.

[4] Centers for Medicare and Medicaid Services, "Provider Enrollment Moratoria," https://www.cms.gov/medicare/enrollment-renewal/providers-suppliers/chain-ownership-system-pecos/provider-enrollment-moratoria.

[5] STAT News, "Medicare halts enrollment of new hospice, home health providers," May 13, 2026, https://www.statnews.com/2026/05/13/medicare-halts-enrollment-of-new-hospice-home-health-providers/.

[6] Hospice News, "CMS Launches National Hospice, Home Health Enrollment Moratorium," May 13, 2026, https://hospicenews.com/2026/05/13/cms-launches-national-hospice-home-health-enrollment-moratorium/.

[7] Ropes & Gray, "CMS Announces Nationwide Moratoria on Hospice and Home Health Agency Medicare Enrollments — Key FAQs for Hospice Providers and Home Health Agencies," May 2026, https://www.ropesgray.com/en/insights/alerts/2026/05/cms-announces-nationwide-moratoria-on-hospice-and-home-health-agency-medicare-enrollments.

[8] Centers for Medicare and Medicaid Services, "Wasteful and Inappropriate Service Reduction (WISeR) Model," https://www.cms.gov/priorities/innovation/innovation-models/wiser.

[9] Centers for Medicare and Medicaid Services, "WISeR Provider and Supplier Guide," https://www.cms.gov/priorities/innovation/files/wiser-provider-supplier-guide.pdf.

[10] CMS Office of Acquisition and Grants Management, "Request for Information — Supplemental Medical Review Contractor (SMRC)," RFI-CMS-SMRC-2026-001, issued April 14, 2026, responses due April 23, 2026.

[11] Centers for Medicare and Medicaid Services, "Supplemental Medical Review Contractor (SMRC)," https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medical-review-and-education/supplemental-medical-review-contractor-smrc.

[12] U.S. Department of Justice, "Acting Attorney General Todd Blanche Issues Memorandum on Creation of National Fraud Enforcement Division," April 2026, https://www.justice.gov/opa/pr/acting-attorney-general-todd-blanche-issues-memorandum-creation-national-fraud-enforcement.

[13] U.S. Department of Justice, "Fraud Division Launches West Coast Strike Force to Target Health Care Fraud Schemes Across Arizona, Nevada, and Northern California," April 30, 2026, https://www.justice.gov/opa/pr/fraud-division-launches-west-coast-strike-force-target-health-care-fraud-schemes-across.

[14] U.S. Department of Justice, "Civil Division Announces FOCUS Initiative for Data Miners Filing Qui Tam Complaints," https://www.justice.gov/opa/pr/civil-division-announces-focus-initiative-data-miners-filing-qui-tam-complaints.

[15] National Health Care Anti-Fraud Association, comments to CMS CRUSH RFI, March 2026, https://www.nhcaa.org/wp-content/uploads/2026/04/NHCAACommentsCRUSH_CMS_RFI_March2026Final.pdf.

[16] Council for Affordable Health Coverage, comments to CMS CRUSH RFI, https://cahc.net/wp-content/uploads/2026/04/CAHC-CRUSH-Fraud-RFI-vFINAL.pdf.

[17] American Medical Association, "Deepfake Doctors Are a Problem. Here Are 7 Keys to Stopping Them," https://www.ama-assn.org/practice-management/digital-health/deepfake-doctors-are-problem-here-are-7-keys-stopping-them.

[18] HHS Office of Inspector General, "Special Fraud Alert: OIG Alerts Practitioners to Exercise Caution When Entering Into Arrangements With Purported Telemedicine Companies," 2022, https://oig.hhs.gov/documents/root/1045/sfa-telefraud.pdf.

[19] GovCIO Media, "CMS Uses Explainable AI to Strengthen Medicare Fraud Detection," https://govciomedia.com/cms-uses-explainable-ai-to-strengthen-medicare-fraud-detection/.