Navigating the FWA Quagmire: Strategies for Upholding Integrity in Healthcare Payment
Foreword
In the landscape of government and commercial healthcare transactions the trio of fraud, waste, and abuse (FWA) stand as formidable challengers against the integrity of payments.
FWA significantly impacts financial resources in the United States, hundreds of billions of dollars of medical spend annually, accounting for 3% to 10% of the total $2.26 trillion in healthcare spending.
Beyond the direct financial losses, the indirect costs are equally significant and can include:
- Increased regulatory compliance cost
- Higher insurance premiums and costs for consumers
- Expenses to implement anti-FWA measures
- Decreased consumer engagement due to mistrust of the system.
- Diminished perception of brand in the marketplace
FWA can take various forms, intentional or unintentional, and can include things like billing for unrendered services using genuine patient information, upcoding to charge for more expensive procedures, performing medically unnecessary services, billing and other administrative errors due to complications in the system, outdated fee schedules, and the list goes on and on.
These intentional and unintentional errors not only waste billions of dollars but can also lead to serious risks for patients, as they may be subjected to unnecessary or even dangerous medical procedures. They also undermine public trust and inflate costs for consumers. This article delves into the cost (financial and otherwise) of these problems and explores strategies for reinforcing payment integrity to ensure payments are made accurately and fairly.