FWA Reporting Checklist for Healthcare Organizations: Steps, Contacts, and Timelines

Compliance with Regulations

Build your FWA reporting framework on clear, current rules. Align policies with federal and state requirements and payer contract terms, then map them to daily workflows so staff can act quickly when concerns arise.

Embed billing rules compliance into operations by defining who is responsible for coding, billing, and monitoring, and by documenting how exceptions and suspected violations are escalated and resolved.

Checklist

• Adopt written policies defining fraud, waste, and abuse, with examples relevant to your services.
• Assign a compliance officer and cross-functional committee with authority to act.
• Document payer-specific requirements and integrate them into procedures and job aids.
• Maintain a sanctions screening process for workforce and vendors.
• Implement privacy and security safeguards to protect evidence and reports.
• Schedule periodic policy reviews and attestations to confirm understanding and accountability.

Accurate Documentation Practices

Accurate, complete clinical and financial records are the backbone of any FWA response. Establish medical record documentation standards that clarify what must be captured, by whom, and when, including signatures, dates, and required elements.

Standardize templates and ensure your EHR supports audit trails and version control. Strong documentation reduces false positives and accelerates investigations when issues surface.

Checklist

• Publish documentation do’s and don’ts for each specialty and care setting.
• Require legible, dated, and authenticated entries that support medical necessity.
• Use structured fields and smart prompts to limit free-text ambiguity.
• Retain source records per policy; preserve metadata for potential evidence.
• Deploy second-level review for high-risk services and modifiers.
• Audit sample records regularly to validate adherence to medical record documentation standards.

Honest Claims Submission

Define end-to-end claims submission protocols that connect documentation, coding, charge capture, and billing. Prevent errors upstream with edits, validations, and segregation of duties before claims leave your system.

When potential FWA is suspected, stop related claims, flag accounts, and document every action taken to prevent repayment delays and compounding exposure.

Checklist

• Map the claim lifecycle with controls at intake, coding, charge entry, and release.
• Automate pre-bill edits for medical necessity, bundling, and frequency limits.
• Separate preparation, approval, and submission roles to reduce conflict of interest.
• Use denial and refund trends to recalibrate claims submission protocols.
• Quarantine affected claims immediately upon allegation and track holds to resolution.
• Document refunds and notifications to payers with clear rationale and calculations.

Internal Audit Procedures

Apply risk-based internal audit methodologies to detect anomalies early and validate corrective actions. Combine prospective reviews (before billing) with retrospective audits (after payment) to cover both prevention and detection.

When investigations occur, follow a consistent protocol for scoping, sampling, interviews, evidence handling, and reporting, ensuring independence and reproducibility.

Checklist

• Maintain an annual audit plan prioritized by risk, volume, and dollars at stake.
• Define standard sampling methods and materiality thresholds.
• Create investigation playbooks for intake, triage, interviews, and documentation.
• Preserve evidence with chain-of-custody logs and secure storage.
• Issue written findings, root-cause analysis, and corrective action plans with owners and dates.
• Verify remediation effectiveness and close actions only after measurable improvement.

FWA Training Requirements

Educate all workforce members on how to recognize, report, and prevent issues through role-based FWA training programs. Reinforce learning with short, periodic refreshers and scenario-based exercises.

Track completions and knowledge checks, and tie training gaps to performance reviews to drive accountability across departments and locations.

Checklist

• Deliver onboarding FWA training within the first weeks of hire and annual refreshers thereafter.
• Provide role-specific modules for clinicians, coders, billers, and supervisors.
• Use real-world case studies highlighting red flags and reporting steps.
• Capture attestations, quiz scores, and expirations in a centralized log.
• Publicize non-retaliation policies to encourage reporting without fear.
• Measure program effectiveness with incident trends and audit outcomes.

Reporting Fraud Hotline Contacts

Make it easy to report concerns through multiple, well-publicized channels. Define fraud hotline reporting procedures that allow anonymous and confidential intake and guarantee prompt, professional response.

List internal and external contacts in every unit and on the intranet, and ensure managers know exactly how to escalate sensitive or high-risk matters.

Checklist

• Offer at least three intake options: anonymous hotline, secure web form, and dedicated email.
• Publish internal contacts: compliance officer, privacy officer, legal counsel, and HR.
• Identify external contacts: payer SIUs, state Medicaid Fraud Control Units, and appropriate government hotlines.
• Define required report elements: who, what, when, where, why, and available evidence.
• Acknowledge reports quickly and communicate next steps while protecting confidentiality.
• Prohibit retaliation and provide multiple avenues to raise concerns if a supervisor is implicated.

Understanding Reporting Timelines

Set clear healthcare compliance timelines from intake to closure. Establish service-level targets for acknowledging, triaging, investigating, and resolving reports, and align them with payer and legal deadlines for refunds or notifications.

Document your escalation matrix for urgent risks and specify how and when leadership, payers, or regulators are notified. Time-box each stage to maintain momentum and demonstrate diligence.

Checklist

• Acknowledge receipt of hotline reports within one business day whenever feasible.
• Complete preliminary triage and risk rating within two to five business days.
• Launch investigations promptly; aim to issue preliminary findings within 30 days on standard cases.
• Process refunds and disclosures within required windows set by law or contract.
• Track and report cycle times and backlog to the compliance committee and executive leadership.
• Close cases only after corrective actions are verified and documented.

Bringing it all together, a strong FWA reporting checklist combines clear rules, solid documentation, reliable billing controls, rigorous audits, targeted training, accessible contacts, and disciplined timelines—so you can detect issues early, respond decisively, and sustain trust.

FAQs.

What are the initial steps to report potential FWA?

Secure any relevant records, avoid altering entries, and submit a report through your designated hotline or web form with facts (who, what, when, where) and available evidence. Notify the compliance officer, assign a triage level, and place related claims or activities on hold pending review.

How can healthcare organizations ensure accurate documentation?

Define medical record documentation standards, use structured EHR templates, require authenticated entries that support medical necessity, and run periodic quality audits. Provide targeted training for roles prone to errors and implement second-level reviews for high-risk services.

Who should be contacted to report healthcare fraud?

Start with internal channels: your compliance officer or anonymous hotline. Depending on the issue, escalate to legal counsel, payer Special Investigation Units, state Medicaid Fraud Control Units, or appropriate government hotlines following your fraud hotline reporting procedures.

What timelines apply to submitting FWA reports?

Set internal targets for quick acknowledgment (within one business day), prompt triage (two to five days), and timely investigations (often within 30 days for standard cases). External reporting or refund timelines depend on payer contracts and applicable laws; document these healthcare compliance timelines in your policy and monitor adherence.