FWA Management

Detect and deter fraud, waste, and abuse (FWA) while meeting compliance and financial goals

CMS RAC

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Mandated processing efficiencies, overlooked claims, overwhelmed or insufficient staff, disparate record systems—all create opportunities for fraud, waste, and abuse (FWA). Financial losses due to FWA, both intentional and unintentional, are estimated to reach tens of billions of dollars each year. Additionally, identity theft, physical risk, and an increase in organized criminal groups are raising the potential for fraud activities to harm patients.

93%
of surveyed payer organizations are likely to recommend Cotiviti.*

 

Cotiviti’s FWA Management solutions help health plans adapt to emerging fraud schemes and compliance requirements.

Designed by credentialed investigators in collaboration with clinical, claims, and regulatory specialists, Cotiviti’s end-to-end FWA Management solutions adapt to emerging fraud schemes and compliance requirements. Our integrated solution set applies data analysis, decisions, and insights from one module into the rules and algorithms of other modules, creating an even stronger anti-fraud solution.

With this solution, our clients have benefitted from results that include:

~35%

increase in case management efficiency

15:1

maximum achieved return on investment (ROI)

>$1M

increase in recoveries from just one provider group for one client

~35%

increase in case management efficiency

15:1

maximum achieved return on investment (ROI)

>$1M

increase in recoveries from just one provider group for one client

FWA Management solution benefits and features

Our modules help solve for a variety of FWA challenges, and include:

  • Sentinel. Get alerts on any providers, members, and pharmacies that pose the greatest risk for potential FWA. Sentinel is an early-warning FWA lead generation tool that leverages proprietary artificial intelligence (AI) to generate analytics that find anomalies and compare peer groups to shine a light on potential FWA.
  • Commander. Manage FWA workloads efficiently and ensure deadlines are met with a module designed to help SIU users. Commander helps them to document and manage their caseloads and deadlines, while allowing management to manage workloads, track case aging, and record financial performance at the user, state, and product levels.
  • Informant. Use an advanced data analysis tool, expressly designed for user-controlled exploration of healthcare data to discover and isolate questionable billing/payment patterns. Informant simplifies the data-mining process while giving your team maximum control, creativity, and efficiency.
  • SIU Services. Benefit from Cotiviti’s SIU team, composed of highly qualified, industry-recognized healthcare fraud subject matter experts. They provide services related to lead generation, lead triage, investigation support, medical records review, policy/procedure review, customized training, and other consulting services

*Source: TechValidate. TVID: C55-FBC-364

A comprehensive, end-to-end solution

Our integrated FWA Management solution set is the adaptive solution to your FWA problems. Relying on a combination of data analysis, decisions, and insights, it’s the anti-fraud solution with a list of benefits that include:


  • More prevention and recoveries. Our integrated solution set applies insights from one module into the algorithms of other modules delivering up to 15:1 ROI for the suite.
  • Unmatched SIU service experience. We deploy a highly accredited, expert SIU team for higher impact vetting leads to augment health plan resources.
  • Increased efficiencies. Our clients spend less time vetting referrals as datamining builds stronger cases. Clients experience 35% increase in efficiency of compiling data needed for reporting with Commander.
  • Regulatory compliance support. Claims verification services support Medicaid regulatory compliance. Consultative support included on compliance audits, policies and procedures, staff development planning and investigative skills training.
  • Extensive clinical and investigative experience. Investigative and clinical support staff credentials include:
    1. Accredited Healthcare Fraud Investigators (AHFI)
    2. Certified Professional Coders (CPC)
    3. Certified Professional Medical Auditors (CPMA)
    4. Certified Pharmacy Technicians (CPhT)
    5. Registered Nurses (RN)

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FWA Management is part of Cotiviti’s Payment Accuracy solution suite.

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