Expert Advice

The effects of the so-called Great Resignation coupled with ever-morphing fraud schemes and other industry factors may make the next 2 – 5 years challenging for payers to staff up with the right number and expertise of investigative resources for the work to be done. We believe this will warrant a renewed focus for payers in at least two areas: outsourcing investigative support and wider use of artificial intelligence/machine learning (AI/ML) for more efficiency.

Cotiviti provides healthcare payers of all sizes with an end-to-end payment integrity solution called Cotiviti Payment Accuracy. We ingest our clients’ historical and real-time claim feeds along with other healthcare data one time to then apply the right payment integrity intervention at the right time: from prepay claim error, waste and abuse prevention to postpay identification and investigation of billing abuse patterns or outright fraud. Of note for fraud, waste and abuse (FWA), Cotiviti provides payers with prepay Claim Pattern Review and postpay FWA Management. Our SIU Services team of 60+ multi-credentialed analysts and investigators support both solutions for a strong return on investment.

While most vendors specialize in one or two areas of payment integrity—such as subscription fraud software—Cotiviti provides a full and synergistic continuum of market-leading solutions that allow the right payment integrity intervention at the right point in the process. Integrated capabilities review all major claim types before they are paid to prevent as much as possible, then appropriately refer suspicious claims and/or providers/members for further review earlier in the process. AI/ML algorithms create a prioritized list of ‘suspected providers’ with higher possibility of exhibiting anomalous behavior than with pre-defined rules alone, driving less false positives, less wasted work, and better outcomes for SIU agents. What’s more, we support both prepay and postpay efforts with our industry leading SIU team of 60+ subject matter experts.

Read our prepayment integrity case study about how a major New York health plan prevented more than $10.5 million by catching a diagnostic testing scheme very early in the process. For other stories, check out our FWA Insights Blog.

The health care industry is undergoing digital transformation, like all other industries, and SAS support on digital transformation also helps us adapt with health care fraud solutions. The COVID-19 pandemic is accelerating this transformation, and it has changed service delivery forever. While younger consumers were already demanding more integration of technology and easier access to care and health management, COVID-19 forced many providers and seniors into adoption. This means integrating technology like artificial intelligence (AI), Internet of Things (IoT) devices, telehealth, and wearables along with those evolving payment models like value-based care and Whole Person Care.

Health care fraud is adapting as well, using technology itself, and continually looking to exploit weaknesses in both advancing technologies and the people who use them. Ransomware attacks and data breaches are just two examples, but both lead to identity theft and back to traditional health care fraud schemes. Therefore, as the industry will be more focused on data security, cloud deployment, and streaming data analytics. Fraud, waste, and abuse solutions must align to these broader strategic goals and how analytics solutions are managed across the business by augmenting human efforts with tools like computer vision, document vision, robotic process automation (RPA), and intelligent decisioning that promote efficiency.

SAS is driven by curiosity and innovation. We’ve used AI since our inception and are investing $1B over 3 years to advance AI technologies. We’re a privately held advanced analytics company that focuses on broad business solutions. SAS is supporting digital transformation in government and major businesses around the globe. Innovation draws from interdisciplinary work with techniques like design thinking. We have a health care focus, but we draw upon on knowledge from other industries. For example, as industry controls improved in financial services, fraudsters took what they learned there and moved into the health care fraud arena. We continually evolve our advanced analytic solutions to stop them.

SAS works with federal and state government, commercial payers, and pharmacy benefit management. A broad perspective helps us see the forest rather than just the trees. Our FWA solutions are flexible by design because the health care system and fraud are continually changing. SAS supports technology change in the health care delivery system (services, med-tech, and pharma), payment and FWA. Therefore, SAS is at the forefront of industry changes and our SMEs use this knowledge to adapt our advanced analytics to stay ahead of fraudsters and to better support FWA fighters.

The value SAS provides is driven by our own values; we are: Curious, Passionate, Authentic, and Accountable. Our mission is to empower and inspire with the most trusted analytics. Again, these collectively drive innovation in all SAS does.

Our greatest value to our FWA community is the desire to help customers achieve their goals. This is especially true with health care where the enormous financial costs of FWA are only exceeded by the human costs FWA can inflict. At SAS, we never forget that health care is about people and making their lives better and longer. The FWA community knows fraud puts patients at risk.

SAS was named a Fast Company 2020 Innovative Team of the Year for its health care fraud fighting partnership with Prime Therapeutics. In 2021, SAS was also ranked a Best Workplace for Innovators by Fast Company for the second year in a row. SAS continually innovates to deliver world-class FWA analytics to our community of health care fraud fighters. SAS is also at the forefront of related technologies like computer vision, text analytics, etc. and uses these to deliver solutions to help our FWA community do more with limited resources.

SAS is passionate about people and using advanced analytics to make their lives better. This starts with our founder, Dr. Jim Goodnight. It’s why SAS has been a named a Great Place to Work® for over 20 years, and SAS is rated a best workplace in countries around the world. We were recently named on People’s 50 Companies That Care list. Therefore, it is not surprising patient safety is a core value of health care fraud SMEs, or that SAS has #data4good efforts around the world. Dr. Goodnight also believes that the best work environment allows employees to do their best work, and he is right.

The Aite Group recently named SAS as Best in Class for health care payment integrity:
“Health care payers are on a quest to make informed decisions as they strive to optimize their claims processing and payment operations. Payment integrity tools play an important role in these optimization initiatives,” said Inci Kaya, Senior Analyst of Aite Group’s Health Insurance practice. “SAS excels in features and functionality, enhanced by an intuitive user interface, ease of implementation and integration, and its customization support.”

Like NHCAA members, SAS is passionate about fighting FWA and it shows.

The industry changes almost daily with new providers, new claims, new schemes, new suspects…but the broader landscape over the next 2-5 years will likely see continued trending towards value-based care.   Value-based care may impact how SIUs analyze claims for potential fraud, waste and abuse (FWA).  The value-based care does not eliminate the need for FWA detection and prevention.  Payers will still need to monitor for medically unnecessary services, upcoding, unbundling, services not rendered, excessive charges, ineligible members/providers and more.   It becomes more of a challenge when the claims data is a blend of claims processed with varying payment methodologies. 

Healthcare Fraud Shield is perpetually evolving to adapt to new laws, new payment methodologies, new codesand so much more.  In order to adapt effectively and swiftly we shift product enhancement priorities and create new ones after a consistent weekly reevaluation of the varying needs.  Those needs are assessed in a few ways:

• Being in constant communication with clients to learn what they are seeing. While many payers share the same product types or are in the same geographic areas, invariably their approaches to assorted scenarios may differ.  A vendor needs to be familiar with not just the broader issue, but how each payer is individually impacted.
• READ, READ, AND READ SOME MORE! We need to stay up to date on new legislation, new rules, work plans, industry shifts and anything that is or could result in loopholes for a new scheme.

COVID-19 exemplified the need to adapt.  Healthcare Fraud Shield quickly pivoted and developed a COVID-19 dashboard, Artificial Intelligence models and about 150 rules. 

Healthcare Fraud Shield provides value in many areas, but most significantly is our commitment to education and training.  We provide the entire industry not just our clients with complimentary content through newsletters, Healthcare Fraud Shield run webinars, podcasts and have served as presenters for industry organizations such as NHCAA, HPA, ACAP, AHIP, HCCA and more.

Healthcare Fraud Shield is solely focused to detecting and preventing Fraud, Waste and Abuse (FWA).  Our teams are not distracted by other products or initiatives and we have a slew of Subject Matter Experts integrated throughout every aspect of our organization.