Fraud, waste, and abuse (FWA) in healthcare can lead to substantial cost increases and negatively impact the quality of care. As the annual rate of healthcare spending in the United States soars beyond $4.9 trillion, the financial impact of FWA also increases, amounting to hundreds of billions of dollars each year. This not only inflates healthcare premiums but also strains resources and undermines trust in healthcare institutions. Addressing FWA effectively is imperative to streamline healthcare operations and reduce unnecessary expenditures.
Challenges for today’s SIU
Traditional methods of managing FWA often rely on manual processes and outdated tools that prove inefficient in handling complex healthcare data. SIUs often face resource constraints, making it difficult to conduct thorough investigations. These manual analyses of claims data can lead to delays and false positives, resulting in wasted resources while overlooking real fraud. As overloaded SIUs struggle to manage FWA cases effectively, advanced technology and human expertise are needed to improve accuracy and efficiency in detecting fraudulent activities.
Reducing FWA with advanced tools and techniques
Effective case management is vital for successful FWA investigations. Advanced tools for SIUs can streamline tracking, reporting, and managing cases to prevent abusive or fraudulent practices, offering real-time updates for better visibility and control and encouraging seamless case tracking.
In tandem with human expertise, machine learning enhances FWA management by detecting complex fraud patterns that traditional methods may overlook. While rule-based engines may spot known schemes, machine learning identifies anomalies early, ranks providers by risk, and prioritizes efforts, ultimately reducing data overload for SIUs.
Read Cotiviti’s new eBook to discover as the key elements of an FWA program in 2025, focusing on:
- How combined specialist review and machine learning can maximize the effectiveness of FWA investigations
- How a managed service model can augment current processes to improve efficiency
- How this new approach to FWA management and prevention drives real-world success
Reducing fraud, waste, and abuse in healthcare demands innovative solutions and a comprehensive strategy. With the help of tech advancements, SIUs can achieve enhanced accuracy, efficiency, and collaboration to effectively reduce costs, improve service delivery, and help ensure a more sustainable and equitable healthcare system for health plan members.
