Think you know how to manage fraud, waste and abuse at your healthcare organization? CMS doesn’t agree. In fact, the promises of change and reform coming from CMS and GAO suggest that our government doesn’t feel that healthcare organizations are adequately managing fraud, waste and abuse at all.
The data we have supports this. FWA estimates are in the billions. Vendors who sell you components of fraud, waste and abuse management programs are doing you a small disservice if they market it as a total solution. They know as we do that, without system visibility, health plans and managed care organizations can only hope to control FWA – not eliminate it.
We aren’t suggesting that you shouldn’t work with technology vendors and third-party business partners – not at all. What we are saying, however, is that health plans need to do more than casually plug in a piece of technology or adjunct services with the hopes it will improve their FWA efforts. A more robust, proactive method is required to eradicate fraud, waste and abuse in your health organization.
The Confusion Surrounding “Overpayments”
By 2026, at least 7% of healthcare spending is expected to be made up of some sort of overpayments. That’s $400 billion. But “overpayments” is a broad term that encompasses everything from mistakes to intentional fraud. Though fraud makes the headlines, the greater percentage of cases – and far costlier to the health plan – are incidents of waste and abuse. And they must be handled differently.
Going back to our earlier point, a health plan must be fully aware that programs to manage fraud, waste and abuse are only a piece of the puzzle. The key to gaining traction at your health plan is visibility. This is why CMS and GAO promote interoperability; they understand that with access to a broader picture (one that is accurate in real-time), you are less likely to get hung up in waste areas like administrative complexity.
We have explored the differences between fraud, waste and abuse in previous blog articles (here and here). To summarize, the primary difference between incorrect payments is intent. Fraud and abuse are categorized as illicit, but only fraud is recognized as willful. Together, fraud and abuse account for7% of healthcare spending. Waste, however, is excessive cost tied to administrative complexity, poor processes, paying costs to suppliers that are too high, and other wasteful spending practices. Clinical waste alone accounts for 14% of healthcare spending. But these are just examples to showcase the breadth of this problem.
In truth, there’s a lot that many health plans don’t know about fraud, waste and abuse – and it’s costing them millions.
What You Don’t Know About FWA – And How to Fix It
In order to fully solve the overpayment crisis in America – including fraud, waste and abuse – health organizations need to shine a light on the areas of this problem that remain uncovered. In 2016, CMS estimated the Medicaid improper payment rate at 10.5% or $36 billion.
A good FWA solution, integrated as part of a broader overpayment prevention program, should be able to make quick progress of identifying leakage at your healthcare organization. Here’s what you don’t know about FWA – and how to fix it:
Waste is Eliminated with Efficiency
Waste and Abuse Outsize Fraud
Overpayments are the Bigger Issue
Take from this report that a payment integrity program must address more than FWA, which will only be partially effective. Innovations to reduce waste need to involve broader overpayment-prevention technologies.
Provider-Payer Partnerships Help Combat FWA
Reporting Should Be Ongoing – And Shared
One Solution for All
Pareo® was created to do something no other payment integrity solution can: plug in at multiple levels to provide health plans with the total system visibility that’s necessary for eliminating overpayment problems. Our innovative technology combats wasteful spending by introducing efficient processes for our clients. These include:
- Unique differences by line of business
- Institutional and provider environment
- Various payment methodologies: DRG, APC, ASC, per diem, fee schedule, percent of charge
- Medical coding and billing
Your health plan’s goal should be to transition efforts from post-pay to prevention.
More from Our Blog:
ClarisHealth Achieves HITRUST CSF® Certification to Manage Risk, Improve Security Posture and Meet Compliance Requirements
HITRUST CSF Certification validates ClarisHealth is committed to meeting key regulations and protecting sensitive information. NASHVILLE, Tenn., April 17, 2019 – ClarisHealth, a leading provider of advanced payment integrity technology for health plans, today...
Health plans considering self-developed payment integrity technology should ask themselves: Do we have the resources to be agile? Iterative Software Development: A cyclical method of software development which focuses on improvements based on continual revisions and...
Pareo® makes it easier than ever to add third-party vendors to your payment integrity operations. Here’s a list of questions to ask new suppliers when interviewing them. A strategic mix of payment integrity suppliers can propel your health plan’s cost containment...