Milliman Selected as Finalist in CMS Crushing Fraud Chili Cook-Off Competition

Glass box AI solution helps combat Medicare fraud

SEATTLE--(BUSINESS WIRE)--Milliman, a global leader in actuarial and healthcare analytics, is proud to announce it has been selected as a finalist in the Centers for Medicare & Medicaid Services (CMS) “Crushing Fraud Chili Cook-Off” Competition. As a finalist, Milliman has unveiled a proprietary AI solution that leverages explainable artificial intelligence (AI) to proactively detect fraud, waste, and abuse (FWA) in Medicare claims, promising new levels of transparency and efficiency for program integrity teams.

Milliman’s solution transforms fraud detection by combining actuarial risk management principles with AI-based anomaly detection. The innovative "glass box" architecture not only flags statistical anomalies in provider billing but also explains the underlying factors, empowering investigators to make informed decisions while maintaining human oversight.

“Medicare fraud is a complex, evolving threat to the integrity of our healthcare system,” said Paul Houchens, Principal and Consulting Actuary at Milliman. “By grounding AI in actuarial science, we ensure our models are accurate, explainable, and defensible, providing CMS the evidence-based tools needed to protect taxpayer resources.”

The Milliman team’s approach is designed to scale across the Medicare program as well as other health payer systems, identifying systemic vulnerabilities and uncovering coordinated fraud networks. The solution’s glass-box evidence package delivers actionable intelligence to investigators, reducing false positives and streamlining case reviews.

“Transparency and accountability are at the heart of our solution,” said Prasenjit Singh, Senior Data Engineer and Architect at Milliman. “Our explainable AI framework not only detects risk but provides investigators with clear narratives and data-driven rationale, ensuring oversight remains both effective and fair.”

For every provider in the CMS Limited Data Set (LDS), Milliman’s entry produces a single risk score: a composite metric that combines behavioral, network, and financial anomalies into an actionable score for CMS officials. The team’s findings underscore the power of integrating actuarial rigor with modern AI technology. “We are honored to have been selected by CMS as a finalist for this innovative approach,” said Adam Hearn, Data Scientist at Milliman. “We see this as an opportunity to help CMS move from reactive to proactive fraud prevention, delivering scalable insights that can be rapidly adopted to safeguard Medicare’s future.”

Milliman looks forward to collaborating with CMS and engaging with industry leaders to further refine and deploy this pioneering solution, strengthening the financial stewardship of Medicare and other publicly funded health insurance programs.

About Milliman

Milliman leverages deep expertise, actuarial rigor, and advanced technology to develop solutions for a world at risk. We help clients in the public and private sectors navigate urgent, complex challenges—from extreme weather and market volatility to financial insecurity and rising health costs—so they can meet their business, financial, and social objectives. Our solutions encompass insurance, financial services, healthcare, life sciences, and employee benefits. Founded in 1947, Milliman is an independent firm with offices in major cities around the globe. Visit us at milliman.com.