Contributor: The Role of Benchmarking and Interoperability in Detecting Fraud, Waste, and Abuse

Previously, I examined how evolving utilization patterns, growing scrutiny of categories such as skin substitutes, and emerging oversight efforts are reshaping conversations around fraud, waste, and abuse. In part 2, I turn to what I believe is the more practical question for health care leaders: how organizations can develop the visibility, context, and analytical capabilities needed to identify these patterns before they become operational, financial, or compliance concerns.

Benchmarking and Interoperability Are Becoming Operational Necessities

One of the biggest operational lessons emerging from recent fraud investigations is that many organizations cannot identify suspicious utilization patterns by looking only at their own data.

Many of the utilization patterns that eventually trigger investigations do not initially appear unusual when viewed inside a single organization. The signal often emerges only when data are benchmarked across larger populations, where meaningful deviations from peer utilization become visible. This creates a challenge for organizations attempting to monitor utilization using only their own data.

An individual provider group, health system, or accountable care organization may not have enough volume to recognize a problematic trend on its own. The signal often emerges only when utilization is compared across broader populations, multiple markets, or large networks of providers.

That broader context is increasingly important because many of today's utilization concerns are not isolated incidents. They are patterns that become visible only through benchmarking and comparative analysis.

These signals can take many forms, including rapid growth in specific Healthcare Common Procedure Coding System categories, geographic concentrations of certain services, unusual hospice discharge patterns, abrupt shifts in coding intensity, unexpected referral relationships, or significant increases in high-cost specialty utilization. Viewed individually, many of these trends may appear reasonable. Viewed across broader populations, however, they can reveal patterns that warrant closer examination.

For example, a provider organization may see a modest increase in skin substitute utilization that appears clinically reasonable within its own population. Yet when benchmarked against regional and national utilization patterns, the organization may find usage rates several times higher than those of peer organizations caring for similar patients.

For organizations operating in contracts with accountability for cost and quality performance, this creates an important operational reality. Effective stewardship increasingly depends on visibility across broader populations and care networks.

In practical terms, organizations can no longer rely solely on internal utilization reviews. Population-scale benchmarking, interoperable data, and medical economics surveillance are becoming foundational capabilities for managing both value-based performance and emerging program integrity risks. Not because every organization needs to function as a fraud investigation unit, but because organizations responsible for managing cost, quality, and utilization performance need better visibility into where patterns diverge from clinical and financial expectations.

The stakeholders that are best positioned operationally are often the same organizations already focused on care appropriateness, referral transparency, and evidence-based utilization management.

Fraud Prevention Is Becoming Part of Health Care Operations

One of the risks in conversations about fraud, waste, and abuse is that health care leaders begin viewing the issue solely through the lens of enforcement. In reality, many of the capabilities required to identify fraud, waste, and abuse are the same capabilities organizations already need to succeed in value-based care.

Organizations that closely monitor utilization trends, evaluate referral patterns, support primary care stewardship, and investigate outlier spending behavior are often simultaneously reducing vulnerability to waste and abuse. The goal is not to transform health care organizations into investigative units. It is to create operational visibility that makes unusual patterns easier to identify and address before they become larger problems.

That visibility also creates opportunities for action. Organizations can educate providers about emerging utilization concerns, improve transparency into downstream referral activity, engage beneficiaries when appropriate, and escalate suspicious patterns through established reporting channels. In many cases, identifying unusual trends early may be more valuable than investigating individual claims after the fact.

Bad actors will continue to exist, and regulatory oversight will remain essential. But as health care shifts further toward accountability for cost and quality outcomes, fraud, waste, and abuse are becoming less of a standalone compliance issue and more of an operational challenge tied directly to care appropriateness, resource stewardship, and performance management. For organizations participating in value-based care, these issues are increasingly moving from the margins of compliance into the core of how care is managed and performance is measured.

The organizations best positioned for the next phase of value-based care may not simply be those that manage utilization effectively. They will be the organizations that can also distinguish appropriate care from inappropriate utilization quickly enough to act before waste, abuse, or emerging fraud patterns affect patients, providers, and performance.