Case study: Integrated prepay and FWA solutions deliver improved claim accuracy

When deploying payment integrity solutions, health plans look to maximize the efficiency of their claim payment operations while preventing inappropriate spending, including fraud, waste, and abuse (FWA). This requires not only advanced analytics, pattern recognition, and machine learning, but the backing of clinical and coding expertise to help ensure the defensibility of edits and payment decisions.

That’s why one Medicare Advantage (MA) plan approached Cotiviti with the goal of leveraging integrated prepay integrity solutions to prevent payment of inappropriate claims through multiple avenues. After implementing Cotiviti’s Payment Policy Management and Coding Validation solutions for automated second pass claim editing and expert review of complex claims, the plan also turned on Cotiviti’s Claim Pattern Review solution to leverage the power of advanced fraud, waste, and abuse (FWA) analytics, pattern recognition, and machine learning.

Read our new case study and learn how the plan has prevented more than $1 million in inappropriate payments in less than one year, improving its payment integrity and protecting members’ benefits through:

  • Ease of implementation
  • Automated prepay review
  • High acceptance rate
  • Focus on a high-volume providers

Read the case study

Our case study also details one specific investigation related to excessive remote monitoring, medical testing, and allergy testing.

With the right technology in place—and the right expertise guiding that technology—payers of all sizes can achieve success in protecting their business and their members from FWA. Read the case study and learn how.


Vince Smith, AHFI, CFE
Vince is a supervisor of investigations for Cotiviti, where he is responsible for analyzing and interpreting claims data to identify potential FWA, conducting extensive fraud investigations on behalf of private insurers, and assisting with the recovery efforts for schemes identified with the investigations. Prior to joining Cotiviti, he was a contracted senior compliance auditor for CMS and worked with the Division of Compliance Enforcement (DCE) to identify fraud and non-compliance occurring within federally funded health plans.

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Case study: Integrated prepay and FWA solutions deliver improved claim accuracy

Vince Smith, AHFI, CFE

Jan 24, 2024

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