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When a health plan special investigative unit (SIU) identifies aberrant patterns in a provider’s billing behavior that could indicate fraud, waste, or abuse (FWA), the next step is to prepare a detailed investigation to support overpayment recovery—or perhaps termination from the provider network and even a law enforcement referral. The most coordinated and efficient health plans also act quickly to ensure any future claims submitted by the provider are reviewed before payment, leveraging their retrospective findings for prospective savings.
Serving more than 1.4 million members, one New York health plan realized major savings following Cotiviti’s identification of a possible massive diagnostic fraud testing scheme—an investigation that led to four New York City-area doctors being arrested and charged for their roles in the alleged fraud. With an end-to-end, pre- and post-pay approach to FWA management, the plan realized more than $10.5 million in savings from this one investigation alone while preventing more than an estimated $41 million in inappropriate spending over three years.