Decision Question This Instrument Addresses
"Are our FWA controls identifying the right risks - or are we simultaneously structurally exposed to fraud and denying more legitimate care than we prevent?"
Each dimension targets a specific failure mode that causes decisions of this type to go wrong. The instrument surfaces the gaps most likely to be consequential - not maturity against an idealised standard.
Structural Exposure
Does your benefit design, coding practice, or service pathway architecture create structural conditions that invite fraud, waste, or abuse - independent of individual intent?
Control Calibration
Are your current FWA controls proportionate to your actual risk profile, or are they generating false-positive denials that cost more in operational and clinical disruption than they save?
False Positive Burden
What is the measurable cost of legitimate care currently being blocked by your FWA controls - and is that cost being tracked, reported, and managed?
NPHIES Audit Alignment
Are you using NPHIES data to distinguish genuine fraud from documentation and process failure - or treating both as the same problem?
Governance Accountability
Is there clear organisational ownership of FWA framework design, control calibration, and ongoing monitoring - distinct from investigative functions?
Typical Audience
CMOs, CFOs, Compliance Officers, Payer Medical Directors, Clinical Governance Leads