Your FWA solution may not be as modern as you think.

Dec 18, 2019

The package may have changed, but the truth is most FWA solutions are still relying on legacy technology. 3 ways to spot the difference.

To prepare for the advancing disruptions to healthcare, most plans we speak with have made some progress towards digital modernization. Often, they’re starting with evaluating their current technology vendors, except for one glaring oversight: fraud, waste and abuse solutions. Did you know, those on the market today are by and large relying on 30 to 40 year old technology? Even many “new” solutions are old products dressed up in new packaging. 

While it can be comfortable to use products we are most familiar with, the problem is, the way we’ve always done things just won’t cut it anymore. It’s very possible that with each passing year, your tried and true technology isn’t quite so effective. Recent advancements in automation and predictive analytics have yielded modern FWA solutions that promote transparency and integration with other systems. 

Got a hunch the FWA solution you’re using may not be as modern as it should be? Get ready to evaluate the evidence for the three big signs of outdated technology. 

1. Reporting Struggles

Your health plan’s FWA solution may be legacy if… it relies solely on rules-based reports. While rules-based reporting is foundational functionality that is still useful, it only addresses known schemes. Fraudsters are changing up their schemes more often than what legacy solutions can keep up with, meaning this outdated approach will leave health plans in a precarious place (and do you really need to combat more false positives?). 

Rules-based reporting is not multi-dimensional and this impairs an investigator’s ability to ascertain legitimate leads. What’s more, some algorithms are actually rules-based which holds them back from being the robust solution so desperately needed in this industry. “Traditional analytics solutions built on relational databases aren’t up to the task,” writes Fierce Health Payer. That’s because fraud schemes are growing increasingly complex, and flat views of them will make legacy FWA solutions a drain on the SIU’s limited resources.

Another reporting issue? The “pull” approach. If your reporting lags and is centered around knowing the right questions to ask, you aren’t accessing the bigger picture. In comparison to a robust data analytics system, pulling reports does not prioritize issues. “Payers should look for platforms that visualize data in an informative way, develop insights using financial big data, and support predictive analytics capabilities,” writes Health Payer Intelligence.

2. Too Little Information on Providers

Lacking visibility into providers? You’re not alone, and it’s yet another sign of older FWA technology. The SIU is by and large missing the ability to efficiently and effectively access provider details, which may range from a particular provider’s associated practices to a lack of visibility into provider education (and no way to measure efficacy of that education). 

When investigators lack visibility into provider data, efforts to obtain that information come at a cost. And while manually communicating to determine provider details or check in on remediation programs, health plans run the risk of a greater cost in the form of provider abrasion. While most fraud schemes may happen at the provider level, very few providers are fraudsters. Communications from the SIU have to be considerably more precise and streamlined than what legacy technologies may afford.

According to NHCAA, “the majority of healthcare fraud is committed by a very small minority of dishonest health care providers.”

Research by the Government Accountability Office (GAO) shows the following trends in provider fraud schemes: 

  • Falsifying claims or diagnoses
  • Participating in illegal referrals or kickbacks
  • Prescribing unnecessary medications to patients
  • Upcoding for expensive, medically unwarranted services

3. Limited to Pay-and-Chase

Health plans are weakened without the proper tools to navigate away from pay-and-chase and towards prevention. But the standard approach to FWA is chasing down improper payments, rather than preventing them. If your current FWA solution does not allow you to effectively detect the risk of an improper payment before that claim is paid, you’re likely using a legacy system.  

Now that the technology is improving, more sophisticated approaches are available. These preventive solutions tend to rely on predictive modeling, but be warned the quality can vary greatly. If a vendor you are considering uses buzzwords like “AI” and “machine-learning” to describe their product functionality, you should know these terms are often used incorrectly. 

It behooves SIU and Compliance teams to drill down into vendor claims of advanced technology to see how predictive capabilities function. Are they dynamic and do they rely on good data? Are they using the right set of metrics? And perhaps more importantly, can these advanced technologies integrate intelligently with a plan’s overall payment integrity processes? Because more and more, effective FWA detection is reliant on more than the SIU. 

So your FWA solution is outdated, now what? 

If you think your FWA solution is no longer up to the task, it may be helpful to focus first on what your organization needs from a technology provider. A true FWA solution is one that gives investigators the tools they need to separate the signal from the noise, quickly and effectively. Advanced integrative technology that provides broader access to real-time data will allow your health plan to modernize the SIU. 


See the ClarisHealth 360-degree solution for total payment integrity in action:

Now’s the time for total payment integrity

See the ClarisHealth 360-degree solution for total payment integrity in action.

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