Tens of billions of dollars are lost each year to healthcare fraud, according to estimates made by the National Health Care Anti-Fraud Association (NHCAA).
As a Third-Party Administrator (TPA), you play a crucial role in preventing fraud, waste, and abuse (FWA) in the healthcare industry today.
Here are the top five ways TPAs can prevent FWA in healthcare:
1.) Implement Comprehensive Fraud Prevention Policies: Develop and enforce robust fraud prevention policies and procedures within your organization. Clearly communicate these policies to all stakeholders, including employees, providers, and members. Establish a zero-tolerance approach to FWA and emphasize the importance of ethical practices.
2.) Conduct Rigorous Claims Review and Auditing: Implement automated and thorough claims review and auditing processes to identify irregularities and potential FWA. Utilize technology-driven tools and data analytics to analyze claims data and detect anomalies. Scrutinize billing codes, medical necessity, invalid claims, duplicate claims, and patterns of overutilization. It’s important to employ both pre-payment and post-payment solutions to catch fraudulent claims.
3.) Educate and Train Employees and Providers: Provide comprehensive training programs to your employees, providers, and stakeholders on FWA detection, prevention, and reporting. Raise awareness about common fraud schemes, red flags, and the consequences of engaging in FWA, and be sure to regularly update training materials to address emerging fraud trends.
4.) Build Strong Provider Relationships: Establish strong relationships with healthcare providers by encouraging open dialogue, addressing any issues or concerns promptly, engaging in regular communication, and making sure providers are aware of your FWA policies and reporting mechanisms. Collaborating with providers can help develop mutually beneficial strategies for FWA prevention.
5.) Leverage Advanced Technology Solutions: Embrace advanced technology solutions, such as predictive analytics, artificial intelligence (AI), and machine learning (ML) algorithms, to enhance your FWA detection capabilities. These tools can help identify patterns, outliers, and suspicious behaviors that may indicate potential fraud. Stay updated with industry advancements and invest in state-of-the-art fraud detection systems.
Note that FWA prevention in the payment integrity process requires a multi-faceted and collaborative approach. Engage in partnerships with other stakeholders, such as industry associations like NHCAA and regulatory bodies to share information and best practices in combating FWA effectively. Utilize FWA automated systems and regularly review and enhance your prevention strategies to stay ahead of emerging fraud threats.
Change the Approach with Naviquis
Naviquis collaborates with TPAs to employ a proactive approach to preventing FWA. We provide a secure, almost real-time solution that utilizes a combination of algorithms, expert systems, computable biomedical knowledge, artificial intelligence (AI), and machine learning (ML) to help identify suspicious and/or inappropriately coded claims before they are paid.
By partnering with Naviquis you’ll also have access to our Provider Relationship Management System (PRMS) which enables you to communicate and foster positive relationships with providers.
This system automatically sends reminders, tracks providers' billing patterns, and shares policies, new developments and educational messages easily.
At Naviquis we are significantly increasing our clients' savings and decreasing provider abrasion and administrative costs by detecting and preventing FWA in their payment integrity processes before payment has been made to providers.
Let’s connect and tackle the billions of dollars in FWA loss by navigating payment integrity together and preventing fraud, waste, and abuse in healthcare.