Fraud, waste, and abuse (FWA) costs the healthcare system billions of dollars annually and further burdens health plans already facing pressure to pay claims accurately and quickly. Fraudulent claims are often paid due to overwhelmed and insufficient staff, disparate record systems, incomplete data sets, and mandated processing efficiencies. When this occurs, health plans must turn to retrospective review and recovery, saving fewer dollars and often increasing provider abrasion.
Cotiviti’s prospective FWA Validation solution analyzes numerous data points to identify potential patterns of FWA early in the process to prevent fraudulent claims from being paid while still meeting prompt-pay requirements. Our solution also flags suspicious providers that warrant immediate investigation, helping special investigative units (SIUs) build ironclad cases to stop bad actors.
Identify claims tied to aberrant provider patterns in utilization, coding mismatches, and outlier billing activities
Apply retrospective learnings prospectively
Meet prompt-pay requirements to avoid fines and penalties
FWA Validation collects data based on utilization, financial profiles, and documented high-impact schemes to create an “Index of Suspicion” for every provider and their patterns around at-risk dollars. This helps identify providers with the highest probability of FWA. Cotiviti also applies logic-based rules to many invoices and claim types, and user-defined rules allow health plans to monitor procedure codes, modifiers, providers, and members prospectively. Our analytics also lower false-positive rates, providing an extra layer of assurance for health plans.
With FWA Validation, health plans see increased staff productivity without extensive training. And because the solution maximizes resources already in place, it seamlessly integrates even with small and mid-sized health plans. FWA Validation 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 has more than 50 specialists, including RNs and certified fraud professionals, who 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.
Backed by these specialists, one Cotiviti Managed Medicaid client saw a 14:1 ROI after implementing FWA Validation. Cotiviti also saved one health plan about $12 million by working with only 0.4% of its total provider population prospectively.
FWA Validation integrates with Cotiviti’s post-pay FWA solutions to apply retrospective knowledge and behaviors to prospective edits. And both our prospective and retrospective solutions interoperate with our case tracking platform for a seamless workflow. Combined, Cotiviti’s wide array of FWA solutions empower health plans to mitigate FWA throughout the entire claim payment lifecycle.
Cotiviti’s highly qualified team of 50+ specialists and medical directors provides all aspects of program integrity support