Prior to the pandemic, claims fraud, waste and abuse (FWA) was a priority issue for health plans aiming to improve both care quality and the member experience. But, accelerated by the pandemic, health plans are now grappling with compounding operational challenges — from aberrant services related to COVID-19 diagnoses, to service shifts, to uncontrolled telehealth expansion and, of course, labor shortages. These converging challenges has brought a sense of urgency to the need for a new payment integrity (PI) architecture, including complete process re-engineering and AI, automation and analytics enablement.
