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Reducing Health Care FWA Losses – Find Your Focus

Blog: Enterprise Decision Management Blog

Medical insurance form

Health care payers use a variety of strategies, tools and solutions to fight fraud, waste and abuse (FWA) in their fee-for-service healthcare claims.  A key component of an effective payment integrity strategy is to focus on your most productive targets:  Who or what should be the focus of your payment integrity program?

Here are some things to think about:

How do you most effectively target your payment integrity efforts?

The most effective approach to targeting your efforts is to score your claims, providers and procedures for likelihood of FWA using xAI and ML, and then sort your scored results to focus where the greatest amount of money is at risk.

An effective payment integrity strategy, like any part of your payment integrity program, depends upon having stakeholders from areas such as Legal, Claims Operations and Provider Relations on board. Engage your stakeholders in your strategy to maximize the results that you achieve in the mitigation of FWA losses.

Be prepared for change because the people who inappropriately take your money are entrepreneurial. Make sure that your payment integrity solution can keep up with the bad guys. Agile xAI and machine learning are features that will allow your solution to do this.

We welcome your comments.  Stay tuned for my next post on health care fraud, waste and abuse.

The post Reducing Health Care FWA Losses – Find Your Focus appeared first on FICO.

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