Fraud, Waste, and Abuse (FWA) remains one of the most persistent challenges facing the healthcare industry. In a sector valued at over $5 trillion in 20241, billions of healthcare funds are lost each year due to FWA.
In 2025, CMS implemented several initiatives to combat FWA, and strengthen Program Integrity, shifting from a traditional “pay and chase” model to a more proactive “stop and caught” approach2. Furthermore, the White House recently launched a dedicated task force focused on combating fraud within federal benefit programs. This task force includes representatives from multiple federal departments – such as Treasury, Justice, Agriculture, Labor, Health and Human Services, and others – as needed. Its mission is to accelerate a nationwide effort to curb FWA3.
While some level of misconduct will always exist, taking a proactive approach to “get it right the first time” is essential to avoiding improper payments and reducing FWA exposure, preventing audits and denials, and reducing adverse findings that can negatively impact an organization both financially and reputationally. Additionally, the day-to-day audit and denial processes can impose substantial financial strain to healthcare organizations. Strengthening internal controls is a prudent way to protect both staff capacity and organizational funds from the significant costs associated with audits and denial management.
Investing in prevention pays off.
Adopting a forward-thinking approach, shift left approach—eliminating errors before they occur, providing ongoing education, and establishing safeguards that catch issues early in the process—such as billing edits and other controls that identify mistakes prior to claim submission—is critical. Consider the establishment of an operational excellence and monitoring framework comprised of key components such as current awareness, ongoing remediation, analysis, process improvement, education & training, and ongoing monitoring to ensure payment integrity.
Current Awareness: This approach begins with staying up to date on the numerous regulatory and coding changes, analyzing how these updates impact your organization, and proactively communicating them across your teams.
Ongoing Remediation: As audits or denials occur, prioritize the review of impacted claims, leverage technology to determine accurate reimbursement values, and outline the necessary corrective actions along with the creation of payer specific appeal strategies.
Analysis: Perform trend analysis to classify denied or audited claims by type, location, and reimbursement impact. Use these insights to prioritize next steps, including conducting root cause analysis to identify the underlying issues, needed corrective actions and initiating appropriate claim remediation.
Process Improvement: Identify opportunities, through current awareness efforts or trend analysis, to strengthen existing processes by examining areas such as Clinical Documentation Improvement programs, the Charge Description Master, charge capture workflows, and billing or claim review edits. Evaluate current internal controls in place and use these insights to implement targeted changes that prevent future issues.
Education & Training: Implement training programs around coding & regulatory updates, trends identified, revised or new policies & procedures, updated processes or updated edits established to decrease or eliminate future issues.
Ongoing Monitoring: Conduct continuous monitoring to ensure that identified issues are fully resolved and that corrective actions remain effective. Ongoing monitoring can further identify areas of weakness for analysis and further improvement.
Contact Wolters Kluwer to see how MediRegs resources support each component of this framework and organizational efforts to shift left in the prevention of improper payments.
References
1. https://www.cms.gov/data-research/statistics-trends-and-reports/national-health-expenditure-data/nhe-fact-sheet
2. https://www.cms.gov/fraud
3. Presidential Actions: ESTABLISHING THE TASK FORCE TO ELIMINATE FRAUD, March 16, 2026
