Case Study: New York Health Plan Provider achieves $10.5M recovery and prevents $41M in improper payments with Cotiviti

New York health plan cracks massive diagnostic testing scheme for pre-pay FWA savings

New York Health Plan Provider, which serves more than 1.4 million members across Medicare and Medicaid lines, faced a coordinated diagnostic testing fraud scheme after member complaints and analytic alerts flagged “impossible days,” claims without referring providers, and alleged unnecessary tests and cash inducements. Cotiviti’s SIU and FWA teams, using its FWA Validation capabilities, were engaged to investigate and validate the suspicious billing patterns.

Cotiviti implemented an end-to-end pre‑ and post‑pay approach—including prospective FWA Validation, expanded pre‑payment review and link analysis for law enforcement—leading to terminations, arrests and an indictment tied to the scheme. As a result, the plan saved more than $10.5 million from 2015–2017 and avoided an estimated $41 million in inappropriate spending over three years across more than 200 providers; Cotiviti’s work also supported criminal referrals that named multiple providers in a large fraud indictment.