ATI Healthcare FWA Prevention Checklist: Policies, Training, Monitoring, and Reporting

This ATI Healthcare FWA Prevention Checklist gives you a practical, step-by-step framework to deter, detect, and respond to healthcare fraud, waste, and abuse. It aligns daily operations with legal and ethical standards while making Compliance Monitoring and FWA Detection routine parts of care delivery and revenue cycle work.

Establish FWA Prevention Policies

Clear, enforceable policies are the backbone of prevention. They translate laws and payer rules into repeatable behaviors that protect patients, payers, and your organization.

Core policy documents to publish and maintain

• Enterprise Code of Conduct that defines integrity expectations for all workforce members and leaders.
• FWA Prevention and Detection policy covering accurate billing, documentation, medical necessity, and claims submission standards.
• Conflicts of Interest, Gifts and Gratuities, and Vendor/Referral Management policies to avoid inducements.
• Privacy and Security policies to meet HIPAA Compliance, including minimum necessary and secure PHI handling.
• Non-Retaliation Policy that guarantees protection for good-faith reporters.
• Policy governance: version control, annual review, and attestation requirements.

Legal anchors to cite within policies

• False Claims Act: prohibits submitting or causing submission of false or fraudulent claims.
• Anti-Kickback Statute: bans remuneration to induce referrals for items or services reimbursable by federal programs.
• Stark Law: restricts physician self-referrals for designated health services without a valid exception.
• HIPAA Compliance: mandates safeguards for privacy and security of protected health information.

Practical setup steps

• Designate a Compliance Officer and a multidisciplinary Compliance Committee with board reporting.
• Complete an initial risk assessment; prioritize high-risk service lines, payers, and vendors.
• Integrate policy checkpoints into onboarding, system workflows, and manager one-on-ones.

Implement Training Programs

Training turns policy into practice. Make it role-based, measurable, and recurring so people know what to do and why it matters.

Audience-specific training

• All staff: orientation plus annual refreshers covering the Code of Conduct, FWA basics, and reporting channels.
• Billing, coding, and revenue cycle teams: deep dives on documentation, modifiers, medical necessity, and claims edits.
• Clinicians and prescribers: medical necessity, incident-to/split-share, telehealth, and referral rules.
• Executives and managers: oversight duties, escalation, and culture-building responsibilities.
• Contractors and vendors: attestations to follow ATI Healthcare policies and FWA Detection standards.

Curriculum content essentials

• Overview of the False Claims Act, Anti-Kickback Statute, Stark Law, and HIPAA Compliance obligations.
• Real-world red flags of FWA (upcoding, unbundling, phantom billing, suspect referral patterns).
• How to use the hotline, web portal, and internal reporting paths; Non-Retaliation Policy reminders.
• Interactive case scenarios, knowledge checks, and attestation of completion.

Delivery and tracking

• Use a learning management system to assign, remind, and document completions and scores.
• Offer microlearning modules and just-in-time refreshers triggered by audit findings.
• Track completion rates, test performance, and late-training trends by department.

Conduct Monitoring and Auditing

Compliance Monitoring is continuous and preventive; auditing is periodic and independent. Together, they verify controls and surface issues early.

Monitoring plan

• Establish KPIs (denial rates, modifier usage, add-on codes, late documentation, and write-off trends).
• Deploy pre-bill edits and real-time prompts to catch missing signatures, diagnoses, or orders.
• Leverage data analytics to spot outliers in utilization, units per visit, or referral clustering.

Risk-based auditing

• Define sampling methods (statistical and targeted) for high-risk codes, services, and payers.
• Audit high-variance areas (telehealth, incident-to, modifier -25/-59, therapy time thresholds).
• Review vendor-billed claims and physician arrangements for Anti-Kickback Statute and Stark Law risks.

Issue resolution

• Document findings, root causes, and severity; assign Corrective Action Plans with owners and deadlines.
• Retrain impacted teams; strengthen workflows and system edits to prevent recurrence.
• Process claim corrections or refunds as required; escalate potential False Claims Act exposure promptly.

Develop Reporting Mechanisms

Multiple, accessible channels increase the likelihood that concerns are raised early and handled fairly.

Channels employees trust

• 24/7 confidential hotline operated by a trusted internal team or third party.
• Secure web portal and dedicated email for compliance concerns and HIPAA privacy complaints.
• Open-door access to managers, Compliance, and HR; optional physical drop boxes.

Non-Retaliation Policy in action

• Zero tolerance for retaliation; communicate protections in training and posters.
• Track and investigate any retaliation allegations separately and swiftly.
• Recognize and reinforce speaking up as a core cultural value.

Triage and investigation workflow

• Intake with time-stamped logs, unique case IDs, and reporter preferences for anonymity.
• Risk-based triage, documented scope, and defined evidence collection steps.
• Closure summaries with outcomes, remediation, and feedback when appropriate.

Enforce Compliance Program Elements

Consistent enforcement drives credibility. Build on recognized compliance program elements and set clear consequences for violations.

Foundational elements to operationalize

• Written policies and procedures aligned to risk.
• Compliance leadership, resources, and board oversight.
• Training and education proportional to role risk.
• Effective lines of communication and open reporting channels.
• Monitoring, auditing, and responsive FWA Detection.
• Enforcement and discipline applied consistently.
• Prompt response, remediation, and continuous improvement.

Disciplinary standards

• Publish progressive discipline guidelines tied to policy categories and severity.
• Document decisions to ensure fairness and defendability.
• Report material issues to leadership and the board; track trends and repeat offenders.

Build Internal Controls and Culture

Controls prevent and detect errors; culture motivates people to use those controls and speak up when something looks wrong.

Preventive controls

• Segregation of duties across scheduling, documentation, coding, billing, and refund issuance.
• Credentialing and OIG/SAM exclusion screening at hire and monthly thereafter.
• Contracting protocols with FMV and commercial reasonableness checks to reduce Anti-Kickback Statute and Stark Law risk.
• Pre-claim edits, NPI/Taxonomy validation, and medical necessity prompts in the EHR/PM systems.

Detective controls

• Post-payment audits, peer reviews, and denial pattern analysis.
• Data analytics (e.g., outlier detection, Benford’s law) to flag unusual billing behavior.
• Hotline trend reviews and periodic culture pulse checks.

Culture-building practices

• Visible “tone at the top,” compliance rounding, and town halls.
• Inclusion of compliance goals in management objectives and performance reviews.
• Celebrate proactive risk reporting and successful remediation.

Meet Compliance Training Requirements

Training must be frequent enough to stay current, documented to prove completion, and tailored to risk. Build cadence and records that stand up to scrutiny.

Cadence and scope

• New hires: complete core compliance, privacy, and FWA modules within the first 30 days.
• All staff: annual training refresh with updates on False Claims Act, Anti-Kickback Statute, Stark Law, and HIPAA Compliance.
• High-risk roles: targeted refreshers during the year based on audit findings and regulatory changes.

Documentation and attestation

• Maintain training logs, scores, attestations, and curriculum versions for the retention period in policy.
• Reconcile rosters monthly to catch gaps; escalate overdue completions to managers.
• Use post-training surveys to gauge confidence and identify content to improve.

Third parties

• Require vendors and contractors to complete equivalent training and sign annual attestations.
• Include training and audit rights in contracts and monitor compliance through scorecards.

Conclusion

By formalizing policies, equipping people through training, validating with Monitoring and Auditing, enabling safe Reporting, enforcing standards, and fortifying controls and culture, ATI Healthcare builds a durable FWA Prevention program. The result is safer care, accurate claims, and resilient compliance performance.

FAQs.

What are the key components of an FWA prevention program?

Effective programs include written policies grounded in the False Claims Act, Anti-Kickback Statute, Stark Law, and HIPAA Compliance; role-based training; ongoing Compliance Monitoring and risk-based auditing; confidential reporting with a strong Non-Retaliation Policy; consistent enforcement; corrective action and refunds when needed; and internal controls supported by a speak-up culture.

How often must healthcare compliance training occur?

At minimum, training should occur at hire and annually for all workforce members. High-risk roles benefit from interim refreshers triggered by audit findings, system changes, or regulatory updates, ensuring knowledge stays current and actionable.

How can employees report suspected healthcare fraud anonymously?

Provide a 24/7 hotline and secure web portal that accept anonymous reports without caller ID or IP logging. Reinforce availability during training, post access details in work areas, and emphasize the Non-Retaliation Policy so people feel safe raising concerns.

What internal controls help prevent healthcare fraud, waste, and abuse?

Key controls include segregation of duties, credentialing and exclusion screening, pre-claim edits and medical necessity prompts, contract FMV reviews, analytics-driven FWA Detection, periodic audits, and reconciliation processes for refunds and adjustments. Together, these controls deter misconduct and surface issues early.