FWA Validation

Prevent fraud, waste, and abuse in healthcare before claims are paid; flag providers that warrant immediate investigation

CMS RAC

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There are many reasons why fraudulent claims get paid—from insufficient staff and disparate record systems to incomplete data sets and mandated processing efficiencies. But health plans don’t need to wait until these erroneous claims are paid, only realizing issues in hindsight.

90%
of surveyed organizations agreed that avoiding improper claims before payment was a challenge that requires payment integrity solutions.*

 

Get ahead of fraud, waste, and abuse (FWA) before claims are paid—with Cotiviti’s FWA Validation prepay solution.

Our FWA Validation prepay solution helps maximize return by preventing the payment of fraudulent, wasteful, or abusive claims. We use numerous data points to identify potential patterns of FWA early in the claim process, impeding suspect claims and flagging those providers that warrant immediate investigation. In doing so, FWA Validation increases staff productivity by proactively identifying potential bad billing behaviors—and helps special investigative units (SIUs) build cases against those committing fraud.

With this solution, our clients see results:

$41M

in prospective savings over a three-year period across more than 200 providers

$10.5M

saved from just one diagnostic testing scheme

4

physicians and 16 alleged accomplices—identified from prepay analytics—indicted on 800+ counts of fraud

FWA Validation benefits and features

Prevent FWA before payment with a solution you can trust. Our FWA Validation solution provides several benefits including:

  • Rapid ROI through automated detection. Detect claims tied to aberrant provider patterns in utilization, coding mismatches, and outlier billing activities—all while meeting prompt-pay laws.
  • Identify potential fraud earlier. Apply retrospective learnings prospectively. Get possible fraud case referrals earlier to help minimize future losses.
  • Save more, improve compliance. Get a positive ROI by only paying on proven savings with no ongoing software fees, and meet prompt-pay requirements to avoid fines and penalties.
  • Boost staff productivity. Increase SIU staff productivity without displacing current resources or systems. Help identify providers with the highest probability of FWA and streamline investigative processes.
  • Gain professional support. Rules, analytics, and SIU analysis are continuously updated by Cotiviti’s cross-continuum payment solutions. And it’s not just software—FWA Validation is powered by more than 50 specialists, including registered nurses and certified fraud professionals.

*Source: TechValidate. TVID: B98-B02-C9A

Maximize ROI with dedicated professionals

With FWA Validation, 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 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’s 50+ 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.

  • AHFI (Accredited healthcare fraud investigators)
  • CDC (Certified dental coders)
  • CHCA (Certified healthcare chart auditors)
  • CPC (Certified professional coders)
  • Practicing pharmacists
  • RN (Registered nurses)

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Ready to learn more? Talk to one of our sales representatives—fill out the form below to schedule a call.