Healthcare payers face growing FWA risks that are outpacing traditional controls. While recoveries remain important, they are costly, burdensome, and often less effective than preventing inappropriate payments before they occur. As improper payments continue to strain government healthcare programs, payers must strengthen oversight, protect members, support provider accountability, and preserve affordability.
Sustainable payment integrity programs require more than just technology or isolated investigations. An intentional prevention strategy supported by disciplined governance, shared accountability, and strong collaboration between health plans and partners is the key to creating an efficient program.
So how can plans shift from reactive risk identification to proactive, strategic action?
Understanding the FWA landscape
Federal and state healthcare integrity programs recover billions each year. In 2024, HHS OIG reported more than $7.13 billion in expected recoveries and receivables. Because many improper payments result from documentation or administrative issues rather than fraud, payers must strengthen controls and reduce preventable leakage.
Several shifts in the FWA landscape are increasing risk, including:
• Access to technology: Bad actors have greater access to advanced tech, including artificial intelligence (AI), which may be used to generate documentation, accelerate questionable billing patterns, or make schemes harder to detect.
• Care options: Telehealth, specialty drugs, behavioral health, school-based services, durable medical equipment, home health, hospice, and phantom provider activity require heightened attention, as FWA is prevalent in these areas.
• Changes in regulations: Regulatory pressure is increasing at both the federal and state levels, even as some traditional controls, such as prior authorization, may face scrutiny or potential reduction.
This combination of higher expectations and evolving schemes requires payers to be more proactive, data-driven, and coordinated. Designing an intentional, effective strategy that considers the current shifts in the market is paramount to preventing waste and abuse.
Designing an intentional prevention strategy
Prepay strategies can reduce the burden of recovery and limit provider abrasion. But intentional prevention requires more planning outside of just maximizing savings. Payers should also consider system accuracy, provider contracts, member impact, clinical appropriateness, and the overall provider experience.
An effective prevention strategy begins with a complete view of the process, from data analysis and provider selection to record review, education, denial decisions, appeals, and ongoing monitoring. It should include clear criteria for when a provider should be placed on prepayment review, when a matter should be referred to a special investigative unit (SIU), and when education or operational edits may be more appropriate.
When setting priorities, exposure rates and velocity must be balanced by quality and member impact. If exposure rates aren’t high for a particular provider or member service quality is compromised, a case should be escalated. Reactive analytics can also be repurposed proactively: when a billing pattern is identified after the fact, teams can use that insight to target records, add edits, or review similar providers.
Governance that strengthens oversight
Prevention strategies can become repeatable practice by deploying strong governance as a mechanism that reduces friction, clarifies accountability, and ensures that decisions are not siloed. Interdisciplinary review meetings, weekly case discussions, and case tracking systems that follow an issue from intake to outcome are just a few examples of where consistency among teams can strengthen programs.
Governance also helps payers balance competing priorities. With the right governance, stakeholders can discuss tradeoffs, align on next steps, and determine whether to continue review, pause activity, educate the provider, or escalate the matter. Teams should be willing to address conflict and update processes as new information emerges.
Aligning teams around a unified payment integrity vision
Payment integrity succeeds when claim operations and SIU teams share a common vision, even when organizational structures differ. Whether a team is organized separately or operating under related leadership, both models require deliberate communication, documented handoffs, and shared definitions of success.
When a Blue Plan client’s payment integrity team identified inappropriate modifier use, the case moved directly to the SIU, where all six open cases resulted in recoveries. Mandatory provider education followed, and operations also added an edit to prevent future incorrect payments tied to repeat modifier misuse. This coordinated approach helped the plan recover funds, educate providers, and strengthen controls to prevent recurrence.
Leadership plays a critical role in reinforcing the vision to identify ownership, define decision rights, empower teams, and create escalation pathways. Cross-training and role flexibility should be encouraged as workforce dynamics change, because frequent process updates can help evolving teams mature quickly and maintain continuity.
Collaboration that drives results
Collaboration turns insight into results by preventing internal duplicate outreach, conflicting provider messages, and delays in decision-making. External collaboration with vendors and plan partners expands visibility beyond a single payer’s data. A health plan may only see its own claims, but a partner with broader data access may identify patterns across multiple plans or markets. That wider view can surface emerging issues earlier.
Cotiviti’s Claim Pattern Review (CPR) identified a provider for prepayment review after detecting suspicious billing patterns in 12 months of claims data. Medical record reviews found a 100% error rate, with nearly all records failing to support billed services. The provider’s failure to submit requested records led to a 70% technical denial rate, while an 85% uphold rate showed most denials remained valid after appeals and subsequent record submissions.
After identifying concerns with the provider, Cotiviti compared findings across other participating health plans to determine whether similar outlier billing patterns existed. Cross-payer analysis helped reveal potentially systemic issues that would not have been visible from a single payer’s data alone, signifying that shared data and partnership can reveal whether similar behavior is occurring elsewhere.
Prevention requires partnership
Modern waste and abuse prevention requires payers to move faster, think more holistically, and work collaboratively. Organizations that succeed are those that treat prevention as an enterprise capability rather than a departmental task. A strong payment integrity strategy is measured by the organization’s ability to protect the healthcare system, preserve trust, and ensure that resources are directed toward appropriate care for the members who need it.
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