6 key capabilities to advance past conventional FWA lead detection


Fraud, waste, and abuse (FWA) in healthcare price the {industry} billions annually, diverting sources from affected person care and driving up premiums. Detecting FWA is not only about figuring out anomalies; IT entails navigating advanced techniques, huge knowledge volumes, and quickly evolving schemes. Conventional strategies typically fall brief, leaving Health plans susceptible to stylish techniques that erode belief and monetary stability and squandering precious sources on handbook evaluations that bear no fruit.  

As fraudsters leverage superior Technology, exploit loopholes, and adapt quickly, Health plans should keep forward by adopting cutting-edge options and proactive methods. A multi-faceted strategy is essential for efficient FWA detection and prevention.

Listed here are six key capabilities Health plans can incorporate into their FWA applications to maximise prevention, restoration efforts, and operational effectivity:

  1. Superior Knowledge Analytics: Leverage AI and machine studying fashions to detect anomalies, determine suspicious patterns, and predict rising threats in actual time, earlier than claims are paid. AI-driven insights allow unmatched precision in pinpointing fraudulent actions and suppliers.
  2. Proactive Case Administration Instruments: Equip investigators with intuitive workflows, automated alerts, case monitoring, superior reporting, and configurable dashboards that every one work off the identical platform. Streamlined investigations enhance productiveness and backbone effectivity.
  3. Prepay-Postpay Collaboration: Undertake instruments that provide each prepay and postpay sample evaluation, and work with different prepay declare modifying options, making use of knowledge evaluation and choices from one module to a different to offer a 360-degree view of supplier behaviors, enhancing decision-making and assuaging administrative burden.
  4. Vetted Leads: Few Health plans have the sources or bandwidth to look by means of lots of of leads solely to find false-positive outcomes. Spend money on applied sciences that ship solely real threats validated by human consultants, considerably boosting your staff’s productiveness.
  5. Person-Pleasant Instruments: Guarantee ease of use by adopting options with fashionable consumer interface, intuitive workflows, and actionable outputs. Instruments which can be easy to implement and use allow groups to adapt rapidly and maximize their effectiveness.
  6. A Extremely Certified Assist Workforce: Discover a companion with the dimensions and investigative expertise wanted to help your program integrity efforts. By incorporating a staff with medical, coding, and anti-fraud expertise, you’ll spot and examine extra patterns extra rapidly and with much less disruption to your staff.  

By integrating these capabilities into your FWA detection framework, you’ll be able to successfully mitigate dangers, get better funds, safeguard member belief, and allocate sources to what issues most: delivering high quality care.

Able to dive deeper? Watch our on-demand webinar, Be part of the Evolution: Advance Past Conventional Lead Detection, to learn the way options like 360 Sample Evaluate can allow your Health to plan obtain:

  • Fast ROI by means of automated detection
  • Elevated effectivity by decreasing false positives
  • Enhanced SIU productiveness with built-in analytics

Watch now

Cotiviti’s 360 Sample Evaluate takes your FWA program from good to nice by integrating prepay Declare Sample Evaluate and postpay FWA Sample Evaluate for complete prevention throughout the declare cost cycle. Our end-to-end answer leverages AI, expert-driven guidelines, and supplier scoring fashions, backed by extremely certified employees. With the potential to avoid wasting an incremental 0.3% or extra off annual declare spend, our industry-leading managed service mannequin delivers distinctive worth with out disruption.

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