Decision Question This Instrument Addresses
"Are we structurally exposed to fraud, waste, and abuse — even if none has been detected?"
What This Instrument Evaluates
Five Assessment Dimensions
Each dimension targets a specific failure mode that causes decisions of this type to go wrong. The instrument is designed to surface the gaps that are most likely to be consequential — not to measure maturity against an idealised standard.
Benefit Design Exploitability
Does your benefit structure contain ambiguities or coverage definitions that invite systematic overuse?
Coding Pathway Arbitrage
Are there coding or pathway combinations that generate systematically higher reimbursement with lower clinical justification scrutiny?
Service Combination Risk
Are there service combinations in your claims data that represent structural overutilisation rather than clinical need?
Control Environment
Are your pre-authorisation, claims review, and audit processes calibrated to detect structural patterns — not just individual episodes?
Data Visibility
Do you have the analytics capability to detect structural FWA patterns before payer audit reveals them?
Instrument Output
Structural exposure index · Top 5 leakage mechanisms (anonymised) · Board-level risk narrative
Typical Audience
CFOs, CMOs, Compliance Officers, Internal Audit, Board Audit Committees
Scope Note: This instrument is strictly analytical and non-investigative. It does not name individuals, providers, or payers. It assesses system-level structural conditions only, in full compliance with HealthElevate's conflict-of-interest framework.
Available Now via Bespoke Engagement
This instrument is in development for standalone release. It can be applied immediately as part of a Full Diagnostic or Strategic Bundle engagement. Contact us to discuss your specific decision context.
Related Instruments
You May Also Need