Erin Rutzler, AHFI, CFE, CPC Cotiviti, Vice President, Fraud, Waste and Abuse Erin Rutzler is responsible for the oversight and strategic direction of Cotiviti’s FWA solution suite. In her role, Erin has been integral in the development of Cotiviti’s FWA solutions over the past eight years. Serving as the company’s primary subject matter expert in investigations and FWA for compliance, client training, sales, and marketing activities, she regularly represents the company at industry conferences such as the National Health Care Anti-Fraud Association’s (NHCAA) Annual Training Conference (ATC). What is one hurdle/challenge that you see for leaders in the health insurer Special Investigations Units today? Increased scrutiny from regulators has made it even more challenging for special investigation units to recover losses due to fraud, waste and abuse. With tighter regulations regarding health insurers’ obligations to report and refer waste and abuse, cross-organizational collaboration with other payment integrity stakeholders has become even more important to maintaining successful FWA programs. How does your organization help? 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. What sets you apart from others? 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. Tell us one success story you would like us to know. 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.