FWA Insights: Catching outlier behaviors in physical therapy claims

Fraud, waste, and abuse (FWA) significantly impact consumers by driving up healthcare costs, increasing insurance premiums, and compromising the quality of care. These inappropriate billings result in billions of dollars in unnecessary expenditures each year, which are ultimately passed on to consumers through higher out-of-pocket expenses and reduced access to essential medical services. One of the best ways to improve the effectiveness of FWA programs is with technology that can identify outlier claim patterns. Insurance fraud in physical therapy practices encompasses a variety of schemes that manipulate billing and treatment processes for financial gain. Common fraudulent activities include billing for services not rendered, upcoding (charging for more expensive services than those provided), and unbundling (separating services that should be billed together to increase reimbursement). Implementing systems that can identify outliers early helps prevent overpayments with rapid detection, increasing the likelihood of recovering funds  and even flagging irregular claims before they get paid at all. Let’s look at a recent investigation by Cotiviti’s own special investigations unit (SIU) that demonstrates the benefits of this approach.