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Best Practices: U.S. Healthcare Payer Fraud, Waste, and Abuse Services

Best Practices: U.S. Healthcare Payer Fraud, Waste, and Abuse Services

The evolution of threats, reform, and technology innovation has combined to raise the profile and impact of fraud, waste, and abuse (FWA) services vendors within health plans. This is reflected in the broadening interest from CFOs, COOs, and CIOs at health plans in FWA analytics as a service and other FWA services. For any payer IT or business leader that wants to take full advantage of FWA solutions, this research offers clear guidance based on peer experience. The number of U.S. healthcare payers planning to invest in fraud, waste, and abuse solutions has risen dramatically over the past year. According to survey results, the number of payers expecting to invest in FWA software has doubled to include almost all of the survey respondents. Other anecdotal evidence also supports the view that this spike in interest extends to FWA services in addition to FWA software and combined services/software offerings. As a result, IDC has conducted in-depth interviews with health plans about FWA solutions and services. In regard to the best practices that health plans employ when hiring and managing FWA services from external vendors, best practices include the following:

This IDC Health Insights report discusses best practices for U.S. payer fraud, waste, and abuse (FWA) services. Outlays for these is rising significantly in 2014–2015, and this report addresses questions that payers have about how to evaluate, select, and manage FWA service providers. IDC Health Insights provides insights based on dozens of structured interviews with health plans that currently employ these services. Extending beyond the traditional realm of the special investigative unit, guidance offered in this research highlights the linkage between quality services and quality software, insights that FWA vendors can offer clients about the healthcare ecosystem, cues for good vendor management, and the benefits of transparency and good communication with FWA services vendors for provider and member interactions.

"The evolution of threats, reform, and technology innovation has combined to raise the profile and impact of FWA services vendors within health plans," says Sven Lohse, research manager at IDC Health Insights. "This is reflected in broadening interest from CFOs, COOs, and CIOs at health plans in FWA analytics as a service and other FWA services." For any payer IT or business leader that wants to take full advantage of FWA solutions, this research offers clear guidance based on peer experience.

Please Note: Extended description available upon request.


IDC Health Insights Opinion
In This Study
Situation Overview
Business Needs
Management Challenges
The Best Practices
The Talent Problem
Quality Services Depend on Quality Software
Building the Foundation on Quality Data
Managing the Relationship
Transparency and Communication
Future Outlook
Essential Guidance
Actions to Consider
Learn More
Related Research
Synopsis
Figure: Payer Fraud, Waste, and Abuse Process Components

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