Out-of-the-box Fraud, Waste and Abuse solutions just don’t cut it for smaller health plans.

If you lead a health plan with fewer than 250k covered lives, you may think you’re out of luck when it comes to a comprehensive FWA solution. Some of the larger technology players are selling smaller payers off-the-shelf solutions for fraud, waste and abuse. But smaller health plans often lack the internal expertise and IT resources needed to make an out-of-the-box FWA solution work to its best advantage.

“We find this oversight to be extremely frustrating for the smaller health plans we speak with,” says Jason Medlin, VP at ClarisHealth. “They feel as if they were sold a solution that was really a problem because it couldn’t quite work in the ways they needed. Customization can be costly after the fact.” What’s more, the pressure of increased CMS audits can make it appear easier to settle for a “quick” solution. Wouldn’t it be ideal if a smaller health plan could instead get the same customized FWA solution that larger plans enjoy?

What’s Wrong with Off-the-Shelf Solutions?

Truth be told, we haven’t met a small health plan that didn’t face unique challenges: markets differ, access to talented staff members varies, and experience with advanced technology ranges. With this in mind, a one-size-fits-all approach to payment integrity technology seems a shade off of what a health plan may actually need. With the misunderstanding that custom solutions aren’t accessible to small health plans, they may instead end up paying for unwanted features that deter usability.

Another red flag is that purchasing an off-the-shelf solution means that a health plan’s history of claims will not be taken into account. Further customization would be required to enable this benefit, and many smaller health plans don’t realize that at purchase. Without insights into past claim history, a plan may unintentionally silo their data and miss out on recovery efforts that payment integrity technology should be able to offer. This is a huge missed opportunity for smaller health plans and a potential risk for FWA program effectiveness.


“Scalability is also a positive factor, with made-to-order systems able to accommodate business growth and contract with any necessary downsizing.” – BCS, The Chartered Institute for IT


Additionally, a pre-packaged solution is in no way able to address a smaller health plan’s specific needs. It will assume and operate on generic pain points, and over time this may lead to workarounds that negate the efficiency gains brought by the technology. While a huge perk of payment integrity technology is advanced analytics and data reporting, these off-the-shelf solutions will only present canned analytics. And the expertise and ability to make up for it with custom report building may be limited at best.

But, even with their constrained resources, smaller health plans don’t have to settle for pre-built payment integrity technology.

ClarisHealth Offers Smaller Health Plans a Custom Technology Solution

For every client (no matter the size), ClarisHealth makes a point of putting together custom solutions based on developing a keen understanding of each health plan’s needs – but without the lead time and expense of a true made-to-order development project. This balance is made possible by the unique flexibility and usability of Pareo®:

Evolves alongside your organization’s changing needs

Guides users in data analytics, without the need for report writer development

Endlessly scalable: Quickly test concepts and add vendors without adding to IT expense

Easily accommodates assorted business lines

Fraud scoring based on health plan’s real claims history

ClarisHealth doesn’t offer these solutions in a confusing you-pick format. Instead, you’ll work with a team of experienced professionals who will assist you in building a customized interface through Pareo®.

Talk to ClarisHealth about how Pareo® can improve your health plan’s payment integrity processes -- and maybe even the healthcare system as a whole. Join our weekly demonstration:

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