As healthcare delivery becomes more complex and bad actors gain access to increasingly sophisticated technology, combatting fraud, waste, and abuse (FWA) is more important than ever. For health plans, staying ahead requires stronger coordination across teams, targeted prepayment strategies, advanced analytics, and the expertise to act on emerging patterns.
We spoke with Erin Rutzler, senior vice president of payment integrity operations at Cotiviti, to learn how health plans can build a more coordinated and proactive approach to preventing FWA.
Why is a coordinated FWA strategy increasingly important for health plans?
FWA schemes are becoming increasingly sophisticated. Bad actors have greater access to advanced technology, including AI, which requires health plans to identify and respond to emerging schemes faster.
Healthcare delivery itself is also changing. Telehealth and other evolving care models provide important opportunities to make care more convenient and accessible for members, but they can also introduce new vulnerabilities that health plans must understand. Add regulatory change to that environment, and a holistic program integrity strategy becomes crucial.
How can payment integrity, SIU, compliance, and operations teams work together more effectively?
Coordination is key. Different teams may be responsible for individual pieces of the program integrity puzzle, but their efforts shouldn't operate in isolation.
Health plans need a holistic view of their initiatives across prepay and postpay. Without it, they risk duplicative or conflicting interventions that can increase provider abrasion and potentially affect members' access to care.
Governance is equally important. A strong governance structure helps plans understand what initiatives are underway, identify the right key performance indicators (KPIs), and measure whether their efforts are working.
Ultimately, coordination and governance help teams work toward a shared goal: reducing wasteful and abusive spending while enabling members to receive the care they need.
What prevents health plans from moving beyond "pay and chase" toward more proactive prevention?
Three challenges stand out: regulatory scrutiny, resource constraints, and technology.
Increasing regulatory requirements add complexity to program integrity efforts, particularly as FWA schemes and healthcare delivery models continue to evolve. At the same time, health plans face pressure to balance cost-saving priorities with the need for specialized expertise. Detecting and addressing sophisticated FWA requires experienced professionals, and that expertise can be challenging to find and afford on an ongoing basis.
Technology presents another hurdle. Moving an initiative from postpay to prepay isn't simply a matter of flipping a switch. Automated prepayment solutions may be relatively straightforward to modify, but the process becomes more complicated when an intervention involves provider communications, member communications, medical record retrieval, or other operational workflows.
Health plans that can balance these considerations while maintaining strong coordination across their program integrity efforts will be better positioned to expand prepayment strategies in a sustainable way.
What does successful coordination look like in practice?
Health plans may structure payment integrity, SIU, compliance, and legal functions differently, but successful programs establish governance that creates visibility across their program integrity initiatives. This helps teams determine where provider education is appropriate, where operational edits can improve results, and where recovery efforts should move downstream to the SIU.
In one example, Cotiviti identified concerning provider behavior in historical data where the underlying issue had not been fully addressed. We referred the provider to the plan, which evaluated the issue through its governance process and implemented a targeted prepay program focused on the specific behavior.
The result was immediate savings from addressing the spend before payment, along with provider education that helped change the behavior and drive repeatable downstream savings.
That approach gives health plans the benefits of advanced technology without relying on an AI model to determine whether an individual claim should be acted upon. Each recommendation is supported by the breadth and depth of expertise our teams bring to the review process.
This interview has been edited for length and clarity.
Learn more about Future-proofing FWA for your plan. Watch the full interview video for a deeper dive on how to:
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Move to prevention by identifying waste and abuse risks before payments are made
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Align teams, governance, and data for a stronger, effective prevention strategy
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Use technology, analytics, and trusted partnerships to stay ahead of evolving FWA threats
