Fighting Fraud, Waste and Abuse for a Healthy Business

Approximately 10.4% of Gross Domestic Product (GDP) is allocated to healthcare, and since 2014, health spending per capita has increased in real terms by an average of 1.7% per year. The Global average of Healthcare Fraud, Waste, and Abuse (FWA) is estimated at 6.19%. In Canada, The Canadian Life and Health Insurance Association (CLHIA) estimates Healthcare Fraud to range from 2 to 10%. Each dollar lost to FWA is a dollar not spent on taking care of our customers! ClaimSecure has zero tolerance for FWA.

The Special Investigations Unit (SIU) team at ClaimSecure is composed of experts, with diversified knowledge covering clinical and investigative backgrounds. They have been assigned the mission to reduce loss caused by Healthcare FWA. How?

By enhancing capabilities and skills to reduce leakage and control claims cost – through the development of ClaimSecure group assets (methodologies, tools, people and IT systems) and action plans.

ClaimSecure management team is committed to fight FWA, raise awareness and share best practices. Our immediate focus is defined by three key success factors:

  • Measuring the impact of fraud and abuse and understanding where key stakes are (e.g. fraud vs abuse – prevention vs recoveries).
  • Getting the right level of investment – primarily in people
  • Securing ownership and execution

Moving forward, our action plan revolves around areas that provide greater efficiencies such as:

  • Further develop and accelerate Counter FWA strategy implementation ensuring a comprehensive, integrated and professional approach to fight FWA
  • Provide customers with new and improved healthcare digital tools to report FWA
  • Foster effective FWA controls, in particular by limiting administrative tasks which could extend delays and impact customer service

In particular, ClaimSecure will identify the sources of leakage and FWA within health claims, quantify the financial consequences and apply corrective measures.

This mission is a challenging one as FWA can appear in many forms. For instance, fraud can come from different sources (providers, brokers, customers, etc.) and there are many possible scenarios (falsification, mistake, omission, etc.).

This vision aims to make ClaimSecure a leader in Counter-FWA within the Health Management Industry, combatting FWA with an emphasis on proactive prevention and detection measures.

Contact: specialinvestigations@claimsecure.com

“ClaimSecure’s approach of managing Fraud, Waste and Abuse (FWA) in Healthcare is a strategic fit with the provision of a new, improved quality of service that provides further protection and support to our customers. Expanded FWA controls are needed to give our customers fair value for money and to control rising costs due to healthcare inflation”

Paul Hardwick - President, ClaimSecure Inc.