FWA Solutions

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

The facts

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.

Benefits

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

Achieve your goals with our proven experience

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:

  • Accredited Healthcare Fraud Investigators (AHFI)
  • Certified Professional Coders (CPC)
  • Certified Fraud Examiners (CFE)
  • Certified Fraud Specialists (CFS)
  • Certified Professional Medical Auditors (CPMA)
  • Certified Pharmacy Technicians (CPhT)
  • Registered Nurses (RN)
  • Medical Directors (MD)
  • Certified in Healthcare Compliance (CHC)

 

Elevate your program with flexible, integrated solutions

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.

 

Sentinel

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

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.

 

Commander

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.

 

Interceptor

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

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).

 

  • Investigative support includes triaging hotline tips and external leads, assessing the need for further investigation, conducting initial investigative analyses, performing research and statistical sampling, reviewing code, and creating workflows to standardize and document processes.
  • Clinical review services include medical review, pre- and post-payment investigations, appeals support, and data analysis for pharmacy lock-in initiatives.
  • Claims verification services include identifying overlap and aberrant billing practices for states with Medicaid managed care organizations that require verification of services.
  • Consultative support includes compliance audit support, policies and procedures refinement, staff development planning, investigative skills training, and best practices consulting.

 

 

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