A partnership-driven approach to waste and abuse prevention

By Erin Rutzler, AHFI, CFE, CHC, CPC, Senior Vice President, Payment Integrity Operations

Healthcare payers are operating in an increasingly complex environment where fraud, waste, and abuse (FWA) risks are evolving faster than traditional controls can respond. Payers can no longer rely only on traditional pay-and-chase models that identify erroneous activity after payment is made. Recoveries remain important but costly, operationally burdensome, and often less effective than preventing inappropriate payment before it occurs. As improper payments represent a significant financial and operational concern across government healthcare programs, payer organizations are under pressure to strengthen oversight, protect members, support provider accountability, and preserve the affordability of care.

Sustainable payment integrity programs require more than just technology or isolated investigations.

An intentional prevention strategy supported by disciplined governance, shared accountability, cross-functional alignment, and strong collaboration between health plans and partners is the key to creating an efficient program.

The goal for payment integrity remains the same—identify risks earlier, reduce unnecessary abrasion, improve consistency, and ensure that members receive appropriate, high-quality care. So how can plans shift from reactive risk identification to proactive, strategic action?

Understanding the current FWA landscape

Federal and state healthcare program integrity efforts recover billions of dollars annually. In fiscal year 2024, the U.S. Department of Health and Human Services Office of Inspector General (HHS OIG) reported more than $7.13 billion in expected recoveries and receivables resulting from investigations and audits involving Medicare, Medicaid, and other federal healthcare programs. Importantly, not every improper payment is fraudulent, as many stem from insufficient documentation, administrative gaps, or failure to meet program requirements. But this impact creates urgency for payers to improve 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. For example, after noticing claims not matching the provider's rendered services, one Cotiviti client took on an initiative to randomly sample medical records of high billers. From the specific specialties viewed, the investigator checked to ensure records matched what was billed. This allowed the payment integrity team to proactively improve the integrity of their credentialing and enrollment systems.

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.

Creating FWA risk scores can help determine priorities. After opening a case against a provider, one Cotiviti client uses AI to assign risk scores based on the provider’s claims history and filing habits. The client balances this information with a risk score calculated by their investigators. When setting priorities, exposure rates and velocity must be balanced by quality and member impact—even if exposure rates aren’t high for a particular provider or member service quality is compromised, a case should be escalated.

Reactive analytics can 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 before the issue expands.

Governance that strengthens oversight and accountability

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. These structures create visibility across payment integrity, SIU, claims and compliance, and operations.

Governance also helps payers balance competing priorities. For example, a provider may present a payment integrity concern while also supporting a quality measure or member access initiative. Without the right forum, teams may act independently and create unintended consequences. 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, revisit decisions, 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.

Just as payment accuracy, investigations, and provider operations are interconnected, a provider-centric issue may begin as a coding concern, become an SIU matter, lead to recoveries and education, and then return to payment integrity for monitoring.

When one Blue Plan client’s payment integrity team analyzed data and found evidence of inappropriate modifier use, the case transitioned immediately to the SIU, where all six open cases yielded recoveries. Mandatory education followed for the providers in question and transitioned back to the payment integrity team to run reporting on the training's efficacy. The operations team put an edit in place to ensure that claims would not be paid incorrectly if inappropriate modifier use occurred a second time. This structured communication allowed the plan to recover funds quickly, deliver training on modifier misuse, and edit system operations to prevent the mistake from recurring.

Leadership plays a critical role in reinforcing the vision to identify ownership, define decision rights, empower teams, and create escalation pathways when an action has broader implications. Cross-training and role flexibility should be encouraged as workforce dynamics change, because frequent process updates can help new or evolving teams mature quickly and maintain continuity when changes occur.

Collaboration that drives results

Collaboration remains the practical force that turns insight into results. Internally, collaboration prevents duplicate outreach, conflicting provider messages, and delays in decision-making, whereas 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, markets, or claim types. That wider view can surface emerging issues earlier and help plans prioritize providers that might otherwise appear low risk in isolation.

Cotiviti's Claim Pattern Review (CPR) solution identified one provider for prepayment review after analyzing 12 months of billing data and detecting suspicious billing patterns. An examination of the provider's medical records revealed that nearly every record failed to support the services billed, showing a 100% error rate on reviewed claims. A 70% technical denial rate resulted from the provider's failure to submit requested medical records within required timeframes, while an 85% uphold rate indicated that most denials remained valid after appeals and later record submissions.

After identifying concerns with the provider, Cotiviti compared findings across other participating health plans to determine whether similar outlier billing patterns existed elsewhere.

Using 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.

This case demonstrates that collaboration can directly impact operational responsiveness, including asking partners to evaluate a provider, sharing findings, and developing recommendations based on plan-specific and cross-payer insight.

Prevention requires partnership, discipline, and shared purpose

Modern waste and abuse prevention requires payers to move faster, think more holistically, and work collaboratively. The risks are more complex, the tools available to bad actors are more sophisticated, and the financial stakes remain high. But the solution is not more investigations or edits—instead, an intentional, governed, and unified approach that brings the right people together at the right time is better equipped to make informed decisions.

Organizations that succeed are those that treat prevention as an enterprise capability rather than a departmental task. They use data to identify risk, governance to manage accountability, leadership to align teams, and partnerships to extend visibility. They also balance savings with provider relationships, member protection, quality of care, and operational practicality. Ultimately, a strong payment integrity strategy is not measured only by payments avoided or recovered; it 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.

As SVP of payment integrity operations, Erin provides strategic direction and oversight of Cotiviti’s FWA, Coding Validation, and dental solutions. Serving as the company’s primary subject matter expert in investigations and FWA for compliance, client training, sales, and marketing activities, she regularly represents the company at industry conferences such as the National Health Care Anti-Fraud Association’s (NHCAA) Annual Training Conference (ATC).