Washington, D.C.

Washington, D.C.

San Diego, CA


Collaborating To Stop Fraud, Waste And Abuse

by Rahul Dubey

August 11, 2017

As health plans continue to explore new ways to enhance their capabilities to combat Healthcare fraud, waste, and abuse (FWA), an unorthodox, yet proven approach revealed itself to a group of health industry stakeholders working at the AHIP Innovation Lab in Chicago.

The Problem

Conventional wisdom leads us to believe that post-payment audits and/or a predetermined set of criteria to potentially identify FWA prior to making a payment (AKA rules-based methods) alone are the most effective solutions. Yet we consistently struggle to recoup overpayments and paid FWA claims at dismal percentages. This current predictive and post-payment approach is not only arduous, costly, and a significant drain of resources to identify and build cases against “fraudsters,” it is, more importantly, detrimental to the growing positive payer-provider relationships in our value-based Healthcare era.

The Solution

Through the collective effort of a few of our health plan members, FraudLens, and other key stakeholders at the AHIP Innovation Lab (IL), we now have a proven framework that proactively addresses one of our Healthcare system’s critical challenges. With a near real-time, pre-payment, detection/prevention model to ensure behavior change through education, we have been able to focus on the often overlooked “small-dollar” FWA – i.e., FWA that was more minor but accumulates into significant cost to the industry over time –  and deter bad actors from abusing the system. What makes our proven methodology such an innovative complement to existing efforts to fight FWA is the secret sauce: A multi-vectored approach consisting of four unique and simultaneously run elements that will finally beat back our ineffective delivery models of old.

  1. Clinical Expertise
  2. Informatics
  3. Forensics
  4. Advanced Data Visualization

The Proof

By pairing elements like data and informatics with health plan and provider input, our proven framework stops small FWA from progressing to millions of dollars of undetected fraudulent claims, and does so within a few hours of providers submitting the claims pre-payment.

“This innovative approach around prospective detects and prevents as opposed to the reactive ‘pay and chase.’ It also enhances provider understanding and leads to positive physician behavior change,” said John Burich, Vice President of Strategy and Growth at Passport Health Plan. “This creates a win-win payer-provider collaboration, eliminating the more common adversarial relationship stemming from decades of inaction and fragmented methods.”

Health plans and providers are finding real value in taking a flexible, real-time, pre-payment approach to detecting and preventing FWA. The benefits of such a solution include an immediate increase in overall revenue and a decrease in administrative burdens. This new source of capital enables plans to look to the future, whether its expanding into new markets, investing in infrastructure innovation to enhance care coordination, or developing programs to educate and inform consumer providers.

Payer-provider collaboration is crucial to providing needed, verifiable, and effective care for the consumers we are so privileged to serve. One Integrated Delivery Network (IDN) leader explains, “Older FWA solutions almost always damage a payer-provider relationship by stacking additional administrative burdens onto the providers. This one-of-a-kind near real-time, pre-payment approach has created the needed understanding and trust between innovative payer organizations and our own, high-performing physicians.”

Watch and learn more here.

Rahul Dubey is AHIP’s SVP of Innovation and Solutions and Founder of the AHIP Innovation Lab.