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Fraud, Waste, and Abuse (FWA)

 

The Situation Today

As health care costs keep escalating, the potential for fraud, waste, and abuse does, too. Investigative efforts have yielded some positive results: The White House has reported total recoveries over the past three years (ending in 2011) to the tune of $10.7 billion. And according to one estimate, the number of individuals charged with fraud rose from 821 in fiscal year 2008 to 1,430 in fiscal year 2011 – a nearly 75% increase.

But the technical challenge of sifting through mountains of data for signs of suspicious behavior has overwhelmed the capacity of health plans and law enforcement agencies alike. In addition, health care reform has put Medicare and Medicaid under intense scrutiny, increasing the opportunity for fraud, waste, and abuse in private plans. Health plans need a new paradigm that includes both pro-active analyses of new claims as well as retrospective trending in order to identify instances of fraud.

How HCL Can Help

HCL and its partners have developed a fraud, waste and abuse management framework, enabling customers to benefit from either the full power of an End-to-End framework or a point solution that caters to specific issues. HCL’s Fraud, Waste Abuse (FWA) Management Solution offers services supported by analytical tools that help the Payer’s/PBM’s handle the issue of increasing healthcare fraud, waste and abuse.

HCL provides a full spectrum of services from validation of suspected claims to recovery management of overpaid claims. HCLs FWA services team will ensure that only the most suspicious claims will have to be referred to Payer SIU’s for further investigation and legal action.

The framework’s services are further strengthened by technical and analytical capabilities that detect potential fraudulent claims and aberrant billing patterns in claims. The use of data-driven analytics provides insight to even the most trivial instance of frauds and misuse, enabling the health plan to detect potential fraud and wasteful or abusive billing patterns.

FWA

What You Can Expect

  • ​Analysis on 100 % of claims received
  • Easy integration with Payers’ existing systems
  • Customizable frameworks for proactive analysis and preventive action
  • Claim Line level analysis by Rules Engine and validation services
  • Analysis of historical data to identify suspicious claims
  • Referring the most suspicious claims to Payer SIUs for further investigation and legal action
  • HCL’s team of experts to perform end-to-end claim validation services and recovery management
  • A dashboard that provides analytical reports on trends and patterns of fraud, waste, and abuse 

For more information, write to us at: contact.lsh@hcl.com

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Text Analytics in Healthcare Records & Claims – FWA a case in point
Text Analytics in Healthcare Records & Claims – FWA a case in point

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Fraud, Waste and Abuse Management Solution
Fraud, Waste and Abuse Management Solution
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