How to sequence FWA investigations for greater impact

When instances of fraud, waste, and abuse (FWA) are discovered, typical health plan actions include education, placing a provider on prepay review, pursuing settlement and recovery, or making a criminal referral—but determining the right steps to take and when can be a tricky process. Investigations require teamwork, compliance, and ultimately provider behavioral change to rectify wrongdoing. So how can health plans most effectively measure positive behavioral changes when FWA cases are validated?

Here are some steps you can take to improve FWA prevention and management in your organization.

Sequence investigations efficiently to increase positive behavior change

Reviewing an allegation begins with data analysis to determine if the billing behavior in question should be followed by prepay and postpay review, medical records request, and an assessment of regulations that may have been violated. Prepay and postpay review are tools that can be implemented well before a case escalates to a criminal trial and can determine the whole picture of the provider’s billing behavior. This thorough analysis helps identify wasteful or abusive billing practices and determines the length of time these behaviors have occurred.

A comprehensive investigation may result in positive behavioral change and correct issues identified within a provider's billing history instead of correcting issues that are only observed through a limited review. Pulling from several claim examples to point out areas of noncompliance can help design a comprehensive correction plan for the provider. In addition, consolidating medical record requests to provider offices improves efficiency and reduces abrasion. 

Execute an end-to-end FWA approach with simultaneous pre and postpay review 

When prepay and postpay investigations are performed in conjunction, a health plan maximizes its chance of success in recovering overpayments from improperly billed services. Prepay and postpay review provides more information that health plans can use for provider education so that inappropriate billing can be remediated quickly. This joint review allows opportunity for internal evaluation, establishment of safeguards, and updates to billing policies to help prevent further FWA. It can also strengthen evidence for government referrals to build a criminal case, take corrective action, or establish an educational program.

To give one example from Cotiviti’s own experience, a COVID-19 testing and laboratory site was the subject of a member complaint regarding a COVID-19 test that was paid for but never completed. After submitting record requests and performing careful investigation, Cotiviti’s team discovered the lab was a “phantom provider” that did not actually exist. In fact, its owner was a contracted lab technician for another company who stole patient information and used it to bill for COVID-19 testing and other services that were never rendered, ultimately leading to a federal indictment. By using postpay investigation to quickly implement a new prepay rule, this scheme was evident as fraudulent behavior and stopped quickly thereafter.

Deploy behavioral tracking to determine next steps 

Tracking a provider’s response to prepay review can reveal if an honest mistake occurred or if the provider’s behavior warrants further investigation. Providers who engage in appropriate billing practices are eager to comply with record requests and ask questions during review to better comprehend coverage policies. Active and clear communication with the provider is more likely to result in positive results and reduce provider abrasion. Behaviors that indicate stalling or avoidance to comply with multiple record requests may warrant further investigation. Plan ahead for these obstacles by expanding prepay and postpay reviews at the front-end of the investigation to notify the provider of consequences and keep internal teams informed.

Monitoring providers post-review is an important step to maintain positive billing behavior. A holistic review of suspect provider behaviors to identify all of the billing issues at once causes less provider abrasion, whereas multiple audits and intervention points can put a strain on the relationship. Analyzing data trends and performing quality assurance checks through internal member surveys and random record requests places accountability on the provider organization to prove that changes are consistent. This helps ensure providers are billing within their specialty and complying with new coverage policies. 

Prevent more FWA in 2023 and beyond 

Health plans can improve their FWA prevention by focusing on: 

• Combining prepay and postpay to streamline investigative processes  
• Correcting aberrant billing behavior with historical and current claim reviews 
• Evaluating internal opportunities for updates to existing billing policies by putting new safeguards in place 

Taking these incremental steps will remove silos within your organization, prevent more inappropriate payments, and improve provider relations for better results.