The Government Is Finally Saying What Compliance Professionals Have Been Saying for Years

For years, we've delivered the same message to our clients:

The best compliance program isn't the one that finds problems. It's the one that prevents them from happening in the first place.

Historically, healthcare organizations have invested enormous time and resources responding to audits, refunding overpayments, appealing denials, implementing corrective action plans, and defending investigations. While those activities remain essential, they are reactive by nature.

The most successful organizations take a different approach.

They build compliance into their daily operations so that risks are identified and addressed before claims are submitted, before improper payments occur, and before regulators come knocking.

That philosophy is now being echoed at the highest levels of government.

From “Pay and Chase” to Prevention

According to CMS, Medicare achieved a record $42 billion in fraud, waste, and abuse savings in fiscal year 2025. Even more noteworthy, nearly 70% of those savings resulted from prevention-focused activities rather than recovering money after it had already been paid.

That is a significant shift.

For years, federal enforcement largely followed a "pay and chase" model—pay the claim first and investigate later. Today, CMS is emphasizing provider screening, enrollment integrity, prepayment controls, data analytics, and proactive monitoring to stop improper payments before they leave the Medicare Trust Fund.

In other words, the government's strategy is evolving from reaction to prevention.

Healthcare organizations should be doing the same.

Prevention Has Always Been the Foundation

At ProCode Compliance Solutions, prevention has always been the foundation of our approach. Whether we're performing risk assessments, auditing documentation, evaluating coding accuracy, reviewing billing processes, strengthening credentialing oversight, or implementing compliance programs, our objective has never been simply to identify errors.

Our goal is to help organizations build systems that reduce the likelihood of those errors occurring in the first place.

What a Mature Compliance Program Should Ask

A mature compliance program should answer questions like:

• Where are our highest-risk areas?

• What controls are in place to prevent errors?

• Are we monitoring those controls?

• Are we identifying trends before they become repayment demands or investigations?

• Do our leaders have meaningful data to make informed decisions?

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These are prevention questions—not recovery questions.

AI and Advanced Analytics Make Prevention Even More Important

As artificial intelligence and advanced analytics continue to transform healthcare, this prevention-first philosophy becomes even more important. AI has the potential to identify emerging risks, detect unusual billing patterns, monitor compliance activities, and support better decision-making long before traditional audits would uncover an issue.

But technology alone isn't enough.

Without governance, reliable data, effective oversight, and accountability, organizations simply automate existing weaknesses.

That's why we've long encouraged our clients to think beyond compliance as a regulatory obligation. Compliance should be viewed as a strategic function that protects patients, safeguards revenue, strengthens operations, and preserves organizational integrity.

The Future of Compliance Is Prevention

The recent CMS results reinforce an important lesson for every healthcare organization:

The future of compliance isn't about getting better at recovering improper payments.

It's about becoming better at preventing them altogether.

After years of encouraging clients to invest in prevention, it's encouraging to see the nation's largest healthcare payer embracing the same philosophy. Prevention isn't just good compliance—it's good stewardship of taxpayer dollars, good governance, and good healthcare.