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Combating fraud, waste, and abuse with limited internal resources

Christina Matsiga ( is Product Compliance Manager at Inovalon Inc. in Bowie, MD.

Healthcare is becoming more consumer-driven with greater focus on improving healthcare access and driving better health outcomes from a wellness and preventive perspective. No matter the policy, payment model, or trending of care delivery systems, one element remains constant—that is, the efforts to combat fraud, waste, and abuse (FWA). Federal, state, and private healthcare insurance payers’ program integrity activities are designed to not only propagate this fight against “bad actors,” but to also identify areas to better educate providers, payers, and consumers, as well as to prevent erroneous payments.

Payment program integrity efforts are successful when payers, providers, and consumers have a collaborative working relationship. Government-sponsored health insurance programs, as well as private health insurance plans, set forth their requirements to operate by setting rates, enrolling providers and beneficiaries, contracting with providers, paying claims, and reporting expenditures. Covered benefits may change from year to year, so it is important to maintain knowledge of medical policies and terms of coverage for each health plan prior to conducting data analysis and audits or investigations.

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