Fraud, Waste, and Abuse Mitigation Services

FWA Referral Management and Investigation
High-level review of FWA referrals and the associated case file documents to evaluate red flags and other case file information that may warrant further investigation. This initial review will result in a decision to open or not to open an investigation.

Investigation services include a wide array of activities such as:

  • Informational and resolution interviews of policyholders, caregivers, and providers

  • Vendor coordination (e.g., EVV analysis and investigation coordination)

  • Field investigator/surveillance management

  • Detailed social media and open source investigations and monitoring

  • Investigation database support

  • Overflow investigative management capacity

  • Resolution strategy recommendations

FWA Capability Assessment / FWA Scan
Review organizational FWA mitigation capabilities with a focus on people, processes, and technology. Assessment will include the FWA mitigation capabilities evaluation and the establishment of goals and action plans to develop a client-centered fraud mitigation program. The FWA Scan will review targeted claims files to determine if a referral should have been made that could have led to an investigation for potential fraud mitigation.
FWA Training
Remote web-based or in-person FWA awareness training for claims examiners, managers, call center representatives, and others who are responsible for generating referrals. Training is designed to educate attendees on the importance of their roles in FWA mitigation. Best practice tactics and processes to help identify and mitigate FWA will also be included in the training.
FWA Program Management
Client-customized administration support and coordination, tailored reporting on program activities and results, and development of long-term strategy for the FWA program will be provided.
FWA Program Consulting
Consulting services include development support for client-managed FWA programs and advice on improvement initiatives in the areas of referral and investigation management. Case management tools, LTCi-specific analytic models, and activities needed to get to a desired FWA operating model will also be identified. Project management and support services are also provided to implement recommendations.