Financial losses due to healthcare fraud are estimated to reach tens of billions of dollars each year. Mandated processing efficiencies, overlooked claims, overwhelmed or insufficient staff, disparate record systems, and incomplete reports and data sets can all create opportunities for fraud, waste, and abuse (FWA). In addition, fraud activities are becoming more harmful to patients due to medical identity theft, physical risk, and increasing coordination with organized criminal groups.
Designed with clinicians, claims and regulatory experts, administrators, and data analysts, Cotiviti’s FWA 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.
Prevent FWA to avoid the costs of pay-and-chase
Reduce medical costs by recovering more FWA dollars
Reduce false-positive leads
Increase case management efficiency by ~35 percent
Achieve regulatory compliance
Achieve return on investment (ROI) of up to 15:1
Leveraging more than 23 years of experience with more than 75 FWA clients, Cotiviti provides program integrity expertise that surpasses others in the industry. Our approach helps you better manage your anti-fraud programs and investigative costs, comply with regulatory requirements, and augment your staff—all in the name of supporting recoveries and staying on top of emerging threats. Our extensive clinical and investigative experience and industry-leading software delivers improved program compliance and documented ROI typically ranging from 5:1 to 15:1.
Our investigative and clinical support staff credentials include:
We understand that one size does not fit all payment integrity program situations. That’s why we developed an end-to-end suite of solutions that can be used together or separately. The more solutions that you deploy, the higher your ROI.
Cotiviti’s signature FWA solution is an automated overpayment detection and protection system that helps payers identify potential fraud cases, spot billing misunderstandings and mistakes, and adhere to medical policies. Sentinel uses hundreds of patterns, rules, statistical calculations, utilization measures, financial profiles, high-impact fraud schemes, and predictive detection to evaluate, compare, rank, and score providers and members.
Informant is an advanced data analysis tool that offers ad hoc and guided toolsets to support user-controlled exploration of healthcare data, with the goal of discovering irregularities and isolating questionable billing and payment patterns. Informant supports analysts, investigators, and auditors who need to independently assemble unlimited (and often unpredictable) combinations of mined data and reports, providing the ability to switch directions and follow new data-driven indicators to expand findings.
As your “command center,” this application helps build, track, and learn from FWA caseloads. Commander uses calendars, notifications, and search to support proactive adoption and reinforcement of best practices in case prioritization, investigative work plans, interdepartmental collaboration, and industry-standard financial reporting. Quality review dashboards track goal progress, productivity levels, turnaround times, inventory levels, outcomes, and ROI.
Our pre-payment fraud detection tool uses a powerful analytics rules engine to identify potential patterns of fraudulent or abusive claim submissions much earlier in the process than pay-and-chase activities. Interceptor identifies claims with aberrant patterns in utilization, coding mismatch, and billing activities using a rules methodology that looks at physician utilization, financial profiles, and documented fraud schemes. Identified patterns are analyzed and referred to clients well within prompt-pay requirements, avoiding costly fines and penalties.
SIU Services include a wide range of program integrity services, from augmenting your staff with investigative support to providing a complete and comprehensive outsourced special investigative unit (SIU).