8 CMS AI Use Cases

8 CMS AI Use Cases

CMS continues to incorporate advanced AI techniques across various domains. Let’s delve into some of their key AI initiatives.

  1. Marketplace Appeals Call Center:
    • CMS harnesses the capabilities of Amazon Lex and Amazon Polly in its Marketplace Appeals Call Center. This cloud-based phone system integrates virtual contact center agents and interactive voice response (IVR) functionalities.
    • Amazon Lex facilitates self-service options and virtual agents, while Amazon Polly converts text into speech, enabling the creation of speech-enabled products.
  2. Feedback Analysis Solution (FAS) with NLP and ML:
    • CMS employs the Feedback Analysis Solution to review public comments and data from internal and external stakeholders.
    • Natural Language Processing (NLP) tools aggregate and identify duplicates, enhancing efficiency in the comment review process.
    • Machine Learning (ML) tools identify topics, themes, and sentiment in the dataset, providing valuable insights.
  3. Predictive Intelligence (PI) for Incident Assignment:
    • PI is utilized within the Quality Service Center for incident assignment based on ServiceNow Service Portal data.
    • The solution analyzes user-provided short descriptions using AI to identify keywords and assign tickets to the appropriate group.
    • Regular re-training every 3-6 months ensures the model stays up-to-date and aligned with evolving incident patterns.
  4. Fraud Detection and Investigation Models:
    • CMS employs models utilizing Medicare administrative and claims data to identify potential cases of fraud, waste, and abuse.
    • Machine learning techniques like random forest are used to alert investigators and prioritize potential fraud schemes.
  5. CERRS AI for Classification in Medicare Advantage Risk Adjustment Data Validation Audits:
    • Advanced capabilities including NLP, OCR, AI, and ML are leveraged in Intake PA to automate medical record review functions within MA RADV audits.
    • This reduces manual efforts, modernizing the audit process.
  6. AI for Anomaly Detection and Correction:
    • Several AI applications, such as RAPIDS and RECON, are utilized for anomaly detection, language interpretation, and recommender systems.
    • These applications enhance process efficiency, sentiment analysis, and anomaly correction within CMS operations.
  7. Forecasting and Predicting with AI Models:
    • CMS employs forecasting models to predict future DSH (Disproportionate Share Hospital) payments and drug cost increases.
    • These models analyze historical data, trends, and Part D claims to facilitate early planning, trend analysis, and redistribution strategies.
  8. Innovative Pilots for CMS Section 508 Program:
    • CMS explores innovative pilots using AI to generate a machine-readable Automated Technical Profile for CMS systems.
    • These pilots aim to infer the technology fingerprint of CMS projects, offering insights at different stages of the development lifecycle.

CMS’s continued integration of AI shows its commitment to optimizing healthcare operations. CMS and other agencies will continue to invest in this space, ArtemisHCM is here to help you bridge your data/AI/ML talent gap.