6 key capabilities to advance beyond traditional FWA lead detection

Fraud, waste, and abuse (FWA) in healthcare cost the industry billions each year, diverting resources from patient care and driving up premiums. Detecting FWA is not just about identifying anomalies; it involves navigating complex systems, vast data volumes, and rapidly evolving schemes. Traditional methods often fall short, leaving health plans vulnerable to sophisticated tactics that erode trust and financial stability and wasting precious resources on manual reviews that bear no fruit. ?

As fraudsters leverage advanced technology, exploit loopholes, and adapt rapidly, health plans must stay ahead by adopting cutting-edge solutions and proactive strategies. A multi-faceted approach is critical for effective FWA detection and prevention.

Here are six key capabilities health plans can incorporate into their FWA programs to maximize prevention, recovery efforts, and operational efficiency:

1. Advanced Data Analytics: Leverage AI and machine learning models to detect anomalies, identify suspicious patterns, and predict emerging threats in real time, before claims are paid. AI-driven insights enable unmatched precision in pinpointing fraudulent activities and providers.
2. Proactive Case Management Tools: Equip investigators with intuitive workflows, automated alerts, case tracking, advanced reporting, and configurable dashboards that all work off the same platform. Streamlined investigations improve productivity and resolution efficiency.
3. Prepay-Postpay Collaboration: Adopt tools that offer both prepay and postpay pattern review, and work with other prepay claim editing solutions, applying data analysis and decisions from one module to another to provide a 360-degree view of provider behaviors, enhancing decision-making and alleviating administrative burden.
4. Vetted Leads: Few health plans have the resources or bandwidth to look through hundreds of leads only to discover false-positive results. Invest in technologies that deliver only genuine threats validated by human experts, significantly boosting your team’s productivity.
5. User-Friendly Tools: Ensure ease of use by adopting solutions with modern user interface, intuitive workflows, and actionable outputs. Tools that are simple to implement and use enable teams to adapt quickly and maximize their effectiveness.
6. A Highly Qualified Support Team: Find a partner with the scale and investigative experience needed to support your program integrity efforts. By incorporating a team with clinical, coding, and anti-fraud experience, you’ll spot and investigate more patterns more quickly and with less disruption to your team. ?

By integrating these capabilities into your FWA detection framework, you can effectively mitigate risks, recover funds, safeguard member trust, and allocate resources to what matters most: delivering quality care.

Ready to dive deeper? Watch our on-demand webinar, Join the Evolution: Advance Beyond Traditional Lead Detection, to learn how solutions like 360 Pattern Review can enable your health to plan achieve:

• Rapid ROI through automated detection
• Increased efficiency by reducing false positives
• Enhanced SIU productivity with integrated analytics

Watch now

Cotiviti’s 360 Pattern Review takes your FWA program from good to great by integrating prepay Claim Pattern Review and postpay FWA Pattern Review for comprehensive prevention across the claim payment cycle. Our end-to-end solution leverages AI, expert-driven rules, and provider scoring models, backed by highly qualified staff. With the potential to save an incremental 0.3% or more off annual claim spend, our industry-leading managed service model delivers exceptional value without disruption.

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About the author

Vince is responsible for analyzing and interpreting claims data to identify potential FWA, conducting extensive fraud investigations on behalf of private insurers, and assisting with the recovery efforts for schemes identified with the investigations. Prior to joining Cotiviti, he was a contracted senior compliance auditor for CMS and worked with the Division of Compliance Enforcement (DCE) to identify fraud and non-compliance occurring within federally funded health plans.