Cotiviti Completes Acquisition of Edifecs.
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FWA Pattern Review is part of Cotiviti's
Payment Accuracy solution suite.
Financial losses due to healthcare fraud reach at least tens of billions of dollars annually, exacerbated by schemes such as conducting medically unnecessary procedures, which can cause direct harm to patients. Contributing to this issue are mandated processing efficiencies, overlooked claims, overwhelmed or insufficient staff, fragmented record systems, and incomplete reports and data sets. These factors all create formidable obstacles in the battle against fraud, waste, and abuse (FWA). Many payers attempt to tackle this challenge with in-house solutions or basic FWA detection software, but such efforts frequently lead to squandered resources and time-consuming efforts spent on reviewing false-positive leads.
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Our solution deploys the latest in provider scoring models, including artificial intelligence (AI) and expert-driven rules, and our industry-leading managed service model means you can increase the savings value of your current programs without disruption. Clients also gain access to a modern user interface that fully integrates referral lead detection and case tracking in one application with intuitive workflows and dashboards.
in suspect FWA claims identified for clients in 2023
credentialed investigative and clinical analysts on staff
years of experience in FWA prevention and management
Cotiviti's trained and certified special investigations unit (SIU) analysts fully vet each lead flagged by our AI and expert rules to weed out any false positives or low-value leads. Our approach includes a full range of optional program integrity services, from record retrieval, to augmenting your staff with investigative support, to providing a complete and comprehensive outsourced SIU. Optional integration with Cotiviti’s prepay Claim Pattern Review delivers an end-to-end solution for FWA prevention and management while reducing duplicate provider outreach.
With postpay FWA Pattern Review, health plans gain benefits that include:
With FWA Pattern Review, health plans see increased staff productivity without extensive training. The solution maximizes resources already in place, seamlessly integrating with the processes of health plans of any size. FWA Pattern Review supports analysts, investigators, and auditors who work with extensive and often unpredictable combinations of data and reports, providing them the ability to switch directions and follow new data-driven indicators to expand findings.
We leverage vast clinical experience in many areas, from anesthesia to vascular surgery, to support FWA investigations. Cotiviti's 70+ specialists support all aspects of health plans' payment integrity programs. These professionals mine data and conduct medical record reviews and on average have more than 20 years of proven market experience in FWA. Our team’s credentials include:
