ATI Health Care Fraud, Waste, and Abuse Prevention: Requirements and Best Practices

Effective fraud, waste, and abuse (FWA) prevention protects patients, preserves payer trust, and safeguards ATI’s reputation. This guide details ATI Health Care Fraud, Waste, and Abuse Prevention: Requirements and Best Practices you can apply day to day—so controls are practical, measurable, and sustainable.

Across every function, ATI expects clear governance, rigorous screening, timely reporting, targeted training, risk-based audits, consistent discipline, precise documentation, and ethical billing. Each element works together to deter misconduct, detect issues early, and drive corrective action that lasts.

ATI Compliance Program Implementation

Governance and Accountability

ATI anchors compliance in executive and board oversight, with a designated Compliance Officer and an interdisciplinary committee. This structure ensures policies are current, resources are adequate, and risk areas—such as coding, billing, referral management, and vendor relationships—receive ongoing attention.

Leaders set the tone through a code of conduct, routine communications, and visible participation in walk-throughs and reviews. Managers own first-line controls, while the compliance team independently monitors performance and escalates concerns when needed.

Compliance Program Screening

Robust screening prevents prohibited or unqualified parties from participating in ATI operations. Requirements include pre-hire and recurring checks for exclusions and licensure status, credential verification, vendor and contractor vetting, conflict-of-interest disclosures, and documentation of results. Screening schedules, exception handling, and retention rules are standardized and auditable.

Fraud Detection Mechanisms

ATI pairs culture with technology. Hotline and web reporting (with anonymity and non-retaliation) capture concerns early, while data analytics flag outliers in claims, coding patterns, write-offs, refunds, and scheduling. Automated edits, segregation of duties, and user-access controls reduce opportunities for manipulation.

• Proactive dashboards and trend analyses focused on high-risk services and locations
• Pre- and post-bill edits to prevent and detect improper claims
• Root-cause tracking to verify whether corrective actions truly resolve issues

Reporting and Investigating Violations

Reporting Channels

Employees, contractors, and vendors can report concerns via hotline, web portal, email, or direct manager. ATI prohibits retaliation, encourages early reporting, and provides feedback on resolution status when appropriate. Posters and onboarding materials reinforce options and expectations.

Investigation Protocol

All allegations are triaged by severity and risk. Investigations follow a documented plan: preserve records, define scope, assign investigators, interview involved parties, analyze data, and keep a defensible workpaper file. Timelines are set to ensure prompt handling and transparency.

Outcomes and Remediation

Findings lead to targeted corrective actions—policy updates, retraining, technology fixes, repayment when required, and process redesign. Material issues may be escalated to leadership and, when appropriate, disclosed to payers or authorities. Lessons learned feed back into risk assessments and monitoring plans.

Training and Education Programs

Role-Based Training Requirements

ATI delivers onboarding and annual refreshers for all staff, with advanced modules tailored to risk. Clinicians receive documentation and medical necessity guidance; coders dive into specialty coding and edits; billing teams study claims submission, denials, and refunds; front-desk staff learn eligibility, prior authorizations, and estimate communications.

• Scenario-based learning and micro-modules to reinforce practical decisions
• Knowledge checks with minimum passing thresholds and retest protocols
• Attendance attestation, completion tracking, and automated reminders

Leaders complete training on oversight responsibilities, investigation confidentiality, and how to address retaliation claims. Training calendars incorporate regulatory updates and audit findings to keep content current and relevant.

Monitoring and Auditing Compliance

Internal and External Audits

ATI maintains a risk-based audit plan that blends focused reviews and routine surveillance. Internal audits evaluate coding accuracy, documentation sufficiency, claim lifecycle controls, refunds, and credit balances. External auditors may validate high-risk areas, benchmark performance, and test remediation effectiveness.

• Sampling strategies that mix random and targeted probes for depth and breadth
• Issue grading, quantified impact, and action plans with clear owners and due dates
• Post-remediation validation to confirm sustained improvement

Continuous Monitoring and KPIs

Automated monitoring tracks denials, late charges, write-offs, add-on codes, modifiers, time-based services, and unusual utilization. Key indicators roll up to leadership dashboards, enabling swift intervention and resource allocation where risk is highest.

Enforcement of Disciplinary Standards

Disciplinary Action Policies

Consequences for policy violations are consistent, fair, and proportionate to the behavior and impact. ATI applies progressive discipline—coaching, retraining, written warnings, suspension, or termination—while recognizing differences among human error, at-risk behavior, and reckless conduct.

Supervisors are accountable for creating compliant environments and addressing repeated lapses. Documentation of each step ensures decisions are defensible and aligned with HR guidance and contractual obligations.

Fairness and Consistency

Discipline is applied uniformly across roles and locations. Mitigating and aggravating factors are documented, and comparable cases are reviewed to ensure parity. When the organization contributed to a failure (for example, inadequate staffing or unclear procedures), corrective actions address system causes as well as individual behavior.

Accurate Documentation and Coding

Coding Accuracy Standards

ATI expects coding to reflect the services performed, medical necessity, and the highest supported specificity. Requirements include correct modifier use, adherence to bundling edits, and accurate selection of time- or complexity-based codes. Query processes resolve ambiguities without leading clinicians.

• Periodic coder and clinician education on guideline changes and frequent errors
• Second-level reviews for high-risk encounters and outlier providers
• Issue logs that map errors to root causes and targeted fixes

Documentation Essentials

Clinical notes must be contemporaneous, complete, and individualized—supporting diagnoses, tests, procedures, and treatment plans. Amendments follow controlled workflows with clear timestamps and authorship. Templates are tuned to reduce copy-forward risks and prompt required elements without overdocumentation.

Ethical Billing Practices

Billing Protocol Audits

ATI’s billing controls emphasize accuracy, transparency, and patient trust. Pre-bill scrubs, eligibility checks, authorization verification, and price transparency support clean claims. Post-bill reviews test timeliness, payer-specific rules, adjustments, and refund handling, reducing rework and financial risk.

• Segregation of duties for charge entry, claim submission, and refunds
• Dual approval for write-offs and manual adjustments above set thresholds
• Routine reconciliation of schedules, charges, and claims to prevent leakage

Charge Capture, Refunds, and Credit Balances

All services must be captured once and only once. Identified overpayments are researched promptly and refunded within required timeframes. Credit balances are worked methodically with documented outreach and timely resolution to maintain payer and patient confidence.

Vendor and Technology Oversight

Third-party billing vendors and revenue cycle tools undergo due diligence, contract controls, and periodic performance reviews. Access management, change control, and contingency planning ensure technologies support compliance without introducing new risks.

Conclusion

Together, governance, Compliance Program Screening, Fraud Detection Mechanisms, role-based training, Internal and External Audits, Disciplinary Action Policies, Coding Accuracy Standards, and Billing Protocol Audits form ATI’s integrated framework. When each element is applied consistently, ATI prevents problems, detects issues early, and resolves them decisively.

FAQs

What are ATI's requirements for fraud, waste, and abuse prevention?

ATI requires clear governance, a documented code of conduct, routine risk assessments, Compliance Program Screening for staff and vendors, confidential reporting channels, timely investigations, role-based training, continuous monitoring, Internal and External Audits, consistent Disciplinary Action Policies, Coding Accuracy Standards, and recurring Billing Protocol Audits. These elements work together to deter misconduct and ensure swift, effective remediation.

How does ATI train employees on compliance?

Employees receive onboarding and annual refreshers tailored by role. Modules cover FWA awareness, documentation, coding, billing, privacy, reporting obligations, and manager responsibilities. Training includes scenarios, knowledge checks with minimum scores, attestation, and tracking. Content is updated using audit findings, regulatory changes, and trend data to keep learning relevant and practical.

What internal controls does ATI implement to prevent fraud?

ATI combines Fraud Detection Mechanisms with preventive controls: segregation of duties, access governance, pre- and post-bill edits, automated analytics and alerts, dual approvals for adjustments and refunds, vendor vetting, and exception reporting. Regular reconciliations and oversight meetings ensure that indicators trigger timely investigation and corrective action.

How are violations investigated and enforced at ATI?

Reports are triaged by risk, assigned to trained investigators, and managed under a written plan with preserved evidence, interviews, and analysis. Findings drive corrective actions—policy fixes, retraining, technology changes, repayments when necessary—and are enforced through consistent Disciplinary Action Policies. Significant matters may be escalated to leadership and disclosed to payers or authorities when appropriate.