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Taking a comprehensive approach to FWA management

Better FWA detection for health plans

6 min read


Taking a comprehensive approach to FWA management

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This post is sponsored by Cotiviti.

Combatting fraud, waste, and abuse while maintaining complete compliance and minimizing provider abrasion is difficult for health plans of any size. SmartBrief spoke with Cotiviti’s Lesley Brown, Ph.D., vice president of product management, who shares her insights into the top challenges and opportunities for payers looking to improve their FWA management results and look toward the future of FWA prevention.

Lesley Brown, Ph.D.

What are the top challenges within the fraud, waste and abuse space that health care organizations are facing today?

The biggest challenge and opportunity for health plans in the FWA space today is having readily available access to data that is clean, complete, reliable and current in order to identify fraudulent schemes in their earliest stages—before they develop into multi-million dollar losses where only pennies on the dollar can be recovered.

A current example is the opioid crisis, where payers are struggling to differentiate between those looking to exploit the problem for personal gain from those who are legitimately struggling with pain and addiction. Health plans need and want to be able to appropriately identify those committing actual fraud and distinguish them from providers who may simply benefit from further education, or patients who may benefit from alternative treatments. Insights from good data allow health plans to make these patient distinctions and intervene early.

What are the biggest advantages and challenges of catching fraudulent, wasteful or abusive activities both before and after a medical claim has been paid?

Catching FWA activities before payment has occurred eliminates the costly and tedious process of recovering overpayments, which may or may not be successful. The biggest challenge here is that it often requires access to data a health plan traditionally would not have.

For example, if a provider is billing multiple plans for eight hours of service on the same date, a single health plan will be unable to detect this fraudulent activity by leveraging only its own data. Instead, health plans should work with a partner that can leverage deidentified data pooled across health plans, using machine learning technologies to develop holistic profiles of both patients and providers. This enables better identification of potential FWA and emerging trends.

FWA activities are easier to identify post-pay because health plans have more time to analyze claims data for trends. Performing this analysis enables them to request reimbursement for overpayments with greater confidence. However, a pay-and-chase approach is not a sustainable long-term payment integrity strategy by itself; it simply requires too many resources to realize only a fraction of the success that can be gained with pre-pay FWA prevention.

What are some of the challenges you see with provider abrasion as it relates to investigating FWA in health care today and how can these be overcome?

Health plans know that the vast majority of providers are not committing fraud or otherwise attempting to game the system. These providers, who are generally already overtaxed and struggling with the transition to value-based payment, understandably do not want the additional burden of responding to unwarranted requests for medical records and responding to audits or investigations.

The key to limiting abrasion is open communication between health plan departments. At Cotiviti, we have often seen cases, in small plans especially, where the SIU team is viewed as an enemy of provider relations because of its necessary work auditing provider activity. Working together, the two departments can gain buy-in from providers by re-orienting the conversation to: “here is the documentation you should provide us to help ensure that we can pay your claims as quickly as possible.” 

In cases where you need to recover an overpayment, documentation and provider communication is critical. One of our clients recently was successful in recovering more than $1 million related to upcoding charges by a provider group after sharing a thorough medical review summary and holding a group discussion to explain the health plan’s decisions.

What trends do you see impacting the future of FWA prevention?

Artificial intelligence is perhaps the most significant “game changer” in FWA technology. While human review of course will always be vital, the increasingly vast amounts of data health plans process requires the assistance of automated systems to look for troubling patterns and adapt to new patterns.

The barriers to interoperability are also eroding, paving the way for improved patient data sharing. This will allow providers to see if a patient is seeing other another physician for similar services and prescription fills, which can point to potential substance abuse issues or fraud. Once better data sharing is in place, providers can take a more active role in preventing FWA activities. 

Ultimately, while the billing codes may change, health care fraud schemes tend to stay the same over time. In the 1990s, for example, there was a lot of fraudulent activity around compounded medications for asthma; now, we see numerous examples of fraud related to compounded topical creams. The major evolution is simply that health plans have much more data to sift through, and they will continue to have to adapt their technologies to keep up with it.

What unique value do Cotiviti’s technology and people bring to the FWA management space?

By integrating our FWA systems throughout the entire claim lifecycle, Cotiviti can leverage data mapping from one solution to the next, enabling payers to prepare holistic patient and provider profiles, as I mentioned. We also strictly avoid taking a “one-size-fits-all” approach—one client may simply need a guided toolset to support user-controlled exploration of their data, while another may need automated overpayment detection coupled with a “command center” to manage their caseloads. Others may be looking for a fully outsourced solution, including the support of our special investigative unit. We also see more clients using our pre-payment claim editing and clinical validation solutions to identify potential FWA earlier in the process to avoid pay-and-chase.

What clients appreciate most, though, is our people. We have an experienced team of investigators, clinicians, and statisticians, all of whom are responsive to each client’s unique needs and assist with continually enhancing our solutions by incorporating market-driven feedback.

Lesley Brown, Ph.D., is Vice President of Product Management for Cotiviti, driving the organization’s product strategy for FWA Solutions and Risk Adjustment. She has more than 30 years’ experience in senior roles in product and project management in the health care and pharmaceutical industries. Dr. Brown is the co-author of 10 U.S. patents and has been published in 16 peer-reviewed scientific and clinical journals. She also regularly presents at health care industry conferences.