2025 Survey Identifies the Vendors and Capabilities Driving FWA Detection, Overpayment Recovery, and Claims Accuracy Across U.S. Payers

NEW YORK CITY, NY / ACCESS Newswire / June 2, 2025 / As healthcare payers confront a convergence of regulatory scrutiny, rising cost pressures, and increasingly sophisticated fraud schemes, the demand for advanced claims integrity solutions has reached a critical inflection point. In 2024 alone, the Centers for Medicare & Medicaid Services (CMS) flagged more than $1.9 billion in Medicare Advantage overpayments, while improper payments across Medicare and Medicaid programs surpassed $100 billion. Meanwhile, the HHS Office of Inspector General reported $3.44 billion in recoveries from fraud investigations in FY2023, underscoring the escalating financial exposure.

As AI-enabled fraud schemes continue to evolve faster than legacy detection tools, 74% of payer CIOs report their current systems are unable to keep pace with these threats. In response, a growing number of health plans are embedding enterprise-grade fraud, waste, and abuse (FWA) detection platforms and claims integrity solutions directly into their financial, risk, and compliance ecosystems. These technologies now serve as critical infrastructure to ensure systemic accuracy, early anomaly detection, and closed-loop overpayment recovery.

In its latest national study, Black Book Research presents survey findings from 722 financial, SIU, compliance, and IT leaders, illustrating how payer organizations from regional TPAs to national MA and Medicaid plans are leveraging advanced FWA technologies. Titled "2025 Claims Integrity & FWA Detection: How Payers Are Combating Overpayment Risk Through Smart Technology," the report offers an independent, vendor-neutral evaluation of the technology ecosystem now driving claims accuracy, audit readiness, and financial resilience across U.S. health plans.

Survey Methodology and Industry Urgency

The report is based on validated responses from 722 financial, compliance, SIU (Special Investigations Unit), and IT leaders representing 446 health plans, TPAs, and government-sponsored programs across all U.S. regions. Participants evaluated more than 90 technology vendors and platforms using 18 qualitative KPIs related to: Detection accuracy and AI capabilities; Ease of integration with claims systems; Audit readiness and regulatory compliance support; Real-time alerts and investigator workflows; Overpayment recovery success rates; and Scalability for enterprise-wide claims monitoring. The study achieved a 95% confidence level with a ±4.5% margin of error.

The Rising Stakes of Claims Integrity

With rising claims complexity driven by value-based care, AI-generated codes, and prior authorization discrepancies, payer organizations reported a 32% increase in suspected overpayment cases year-over-year.

Simultaneously, federal and state oversight has escalated. In 2024, CMS alone issued over $1.9 billion in Medicare Advantage overpayment recoupment notices, while Medicaid anti-fraud task forces expanded in 27 states, significantly increasing investigative pressure on health plans.

"Payers can no longer rely on reactive audits or outdated systems," said Doug Brown, Founder of Black Book Research. "FWA detection and claims integrity platforms are no longer optional, they're central to payer financial viability and regulatory survival."

Capabilities Most Valued by Users of Claims Integrity Platforms

According to survey respondents from top-performing payer organizations, the following five capabilities were most frequently cited as critical to their success with fraud, waste, and abuse (FWA) detection and claims integrity technology:

AI-Powered Pattern Recognition

Users emphasized the importance of machine learning-based models that can identify emerging and non-obvious fraud schemes more quickly and accurately than static rules engines. Respondents noted reduced manual review burdens and faster flagging of suspicious claims.

Pre-Submission and Post-Payment Review Capabilities

Survey participants widely supported tools that enable both prospective and retrospective intervention, allowing their organizations to prevent improper payments before adjudication and recover them efficiently after the fact.

Integrated SIU Workflow Management

Respondents reported that platforms offering centralized case tracking, automated alerting, and collaboration tools significantly improved their Special Investigations Unit (SIU) operations. These workflows were linked to faster resolution times and stronger audit readiness.

Regulatory Audit and Reporting Support

Health plan leaders cited the ability to automatically generate documentation and compliance reports for CMS, OIG, and state agencies as a key differentiator. These features were seen as essential for reducing regulatory exposure and ensuring preparedness during audits.

End-to-End Overpayment Recovery Integration

Surveyed users highlighted the value of solutions that provide a closed-loop recovery process, from initial detection to resolution and provider communication. These capabilities were associated with improved recovery rates and fewer administrative delays.

Top 10 Most-Cited Claims Integrity & FWA Vendors in 2025

Health plan executives surveyed by Black Book cited the following ten vendors most often for their impact on fraud detection, improper payment prevention, and claims accuracy:

Codoxo Praised for advanced AI algorithms and flexible anomaly detection, Codoxo continues significant growth, particularly in Medicaid and commercial markets, with its Explainable AI™ and investigator automation.

Cotiviti A dominant force in payment integrity, Cotiviti continues innovation through new AI modules, analytics, and expanded recovery services, reinforcing its market position.

Optum (Fraud Waste & Abuse Solutions) Robust and deeply integrated into payer workflows, Optum's platform excels in analytics, regulatory compliance, and audit automation, with strong presence in large-scale commercial and Medicaid markets.

SCIO Health Analytics (EXL) Noted for predictive analytics, dashboards, and rapid fraud case resolution, SCIO's analytics-first approach is highly valued by payers, particularly for retrospective programs.

IBM (Watson Health / Merative) Leveraging NLP and machine learning, Merative maintains its strength in large payer environments, providing highly visual anomaly detection and adaptable rules engines.

HMS (Gainwell Technologies) Renowned for strong provider network monitoring, especially within Medicaid and dual-eligible programs, HMS remains essential in government-sponsored plan integrity.

SAS Rapidly adopted for healthcare fraud analytics, SAS delivers advanced AI/ML modules, innovative solutions, and scalability, underscored by recent high-profile payer engagements.

ClarisHealth ClarisHealth's Pareo platform offers end-to-end payment integrity and real-time analytics, widely praised for innovation and rapid adoption by major payers.

Zelis Expanding payment integrity capabilities through acquisitions and analytics enhancements, Zelis garners strong client satisfaction, bolstering its FWA detection and recovery offerings.

MultiPlan MultiPlan's substantial investments in AI-driven payment integrity and FWA solutions have yielded significant payer partnerships, emphasizing innovation and seamless integration.

Other top twenty vendors receiving top scores from payer clients include: Verscend (now Conduent), known for its strong presence in government healthcare programs; Equifax, bringing extensive data analytics and fraud prevention capabilities from the financial sector; LexisNexis Risk Solutions, providing data and analytics solutions for fraud detection and compliance; Healthcare Fraud Shield, specializing in fraud detection and prevention solutions for healthcare payers; iHealth Technologies (now HMS), offering payment integrity and analytics solutions; Context4 Healthcare, providing data-driven solutions for payment integrity and risk management; Performant Healthcare Solutions, specializing in payment integrity and recovery services; Vigilant Health, offering fraud detection and prevention solutions; Qlarant, focusing on quality improvement, program integrity, and fraud prevention; and Netsmart Technologies, providing technology solutions for healthcare providers and payers, including fraud detection and prevention tools.

Beyond FWA: Surveyed Health Plans Report Broad Operational Gains

Among surveyed respondents leveraging advanced FWA and claims integrity platforms:

82% reported a noticeable reduction in false positives, resulting in fewer unnecessary provider escalations and improved network relationships.

76% experienced a faster audit response cycle, with an average 28% reduction in turnaround time, credited to automated documentation tools and workflow integration.

69% cited a shortened overpayment recovery timeline, with an average improvement of 11% in resolution speed, enabled by real-time alerts and closed-loop tracking.

64% confirmed enhanced CMS and OIG audit preparedness, including fewer documentation errors, reduced penalties, and increased regulatory confidence scores.

These findings indicate that modern claims integrity systems are delivering enterprise-wide impact, extending well beyond fraud detection to support core payer objectives in regulatory compliance, provider relations, and financial performance.

Why Claims Integrity Now Defines Payer Strategy

As value-based models evolve and fraud tactics grow more sophisticated, claims integrity platforms are now fundamental to payer digital infrastructure. Leaders are embedding FWA prevention tools not only in finance and compliance departments - but across provider contracting, member engagement, and clinical risk management.

"The future of claims integrity is predictive, integrated, and smart," said Brown. "Plans that embed FWA detection across their enterprise are building lasting trust with regulators, stakeholders, and their provider networks."

The full Black Book Research report is licensable now featuring the top twenty client rated vendors, "2025 Claims Integrity & FWA Detection: How Payers Are Combating Overpayment Risk Through Smart Technology," For custom data extracts, benchmarking dashboards, or media interviews:
research@blackbookmarketresearch.com

SOURCE: Black Book Research