Fraud, waste, and abuse (FWA) audits play a crucial role in ensuring healthcare payment integrity by identifying improper payments and enforcing correct coding standards. However, the audit process can also create tension between health plans and providers, particularly when approaches feel overly rigid or punitive. A more collaborative and transparent strategy can help health plans maintain compliance while fostering productive provider relationships.
Understanding the challenges of FWA audits
The standard FWA audit process involves requesting medical records, reviewing documentation, communicating findings, handling provider appeals, and recovering overpayments. Two areas where this frequently causes tension between payers and providers are:
- Medical records requests: Large record requests can be time-consuming, particularly when records are stored across multiple locations or when submission timeframes are tight .
- Overpayment letters: Extrapolated overpayments may seem excessive, and providers may struggle to understand documentation requirements, leading to disputes and delays.
To mitigate these issues, health plan leaders should work with their special investigation units (SIUs) to refine audit methodologies and increase provider education, creating a fair and efficient process that minimizes provider abrasion.
Key strategies for minimizing provider abrasion
Based on Cotiviti’s more than 20 years of experience in FWA investigations, here are our experts’ best practices for working with providers during audits to promote harmonious engagement.
Enhancing medical records requests
- Allow reasonable submission time frames: Granting extensions when appropriate can ease administrative burdens and improve provider cooperation.
- Ensure clear and specific requests: Tailoring requests based on provider specialty and services billed increases the likelihood of obtaining the necessary documentation on the first request, reducing unnecessary follow-ups.
- Optimize sampling methodologies: Adjusting sampling parameters can help minimize the number of records requested while maintaining statistical validity.
Improving overpayment communication
- Timely review completion: Completing audits promptly prevents prolonged uncertainty for providers.
- Transparent reporting: Clearly communicating audit findings, including citations of relevant guidelines and policies, helps providers understand the basis for overpayment determinations.
- Educational vs. recoupable findings: Whenever possible, distinguishing between administrative errors and recoupable overpayments fosters goodwill and encourages corrective action.
- Streamlining appeals: Clearly outlining appeal rights and response deadlines in audit findings letters reduces confusion and helps ensure a fair appeals process.
- Offering settlement and corrective action plans: Providing structured repayment options or corrective action plans gives providers an opportunity to address concerns without severe financial disruption.
- Facilitating direct collaboration: Engaging in direct discussions between auditors and provider coding teams can help clarify issues and expedite resolution.
Proactive provider education: A long-term solution
Over time, health plans and their SIUs can reduce provider abrasion by proactively educating providers about audit processes, coding updates, and compliance expectations. Regular training sessions, newsletters, and policy updates on topics such as evaluation and management (E/M) coding and internal payment policies can help providers avoid common pitfalls and reduce disputes.
By refining audit methodologies and improving provider communication, health plans can effectively address FWA while minimizing provider abrasion. A balanced approach that emphasizes transparency, education, and collaboration leads to more efficient audits, improved compliance, and stronger provider relationships.
Achieve better FWA outcomes with a trusted partner
Cotiviti’s 360 Pattern Review™ helps to reduce provider abrasion by minimizing false positive leads and leveraging advanced analytics to identify improper billing patterns across a broad dataset. This comprehensive methodology enables health plans to detect FWA more effectively while reducing unnecessary provider burden. By integrating this innovative technology into audit processes, SIUs can achieve more accurate findings, minimize disputes, and foster a more cooperative relationship between payers and providers. Read our fact sheet to learn more.
