Fraud, Waste, and Abuse
Fraud, Waste, and Abuse Is Not Just a Compliance Issue.
It Is a Data Problem.
Accountable Care Organizations have always operated in a space that demands balance. Improving outcomes while managing total cost of care is complex enough on its own. Doing it across fragmented systems, multiple providers, and disconnected data sources only amplifies that challenge.
What is changing now is not the mission, but the level of accountability tied to it. As value based care continues to evolve, ACOs are being asked to stand behind their performance with increasing precision. That precision depends on something many organizations are still working toward: true clarity into how care is delivered, utilized, and measured.
The Visibility Gap No One Talks About Enough
Conversations coming out of the National Association of ACOs ACO Forum on Fraud, Waste, and Abuse highlight an issue that feels familiar to many ACO leaders. Organizations are being measured on performance they cannot always fully see.
Total cost of care is influenced by activity happening across the continuum, yet the data that reflects that activity often lives in silos. Claims arrive late. Clinical data varies in completeness. Utilization patterns become clear only after they have already impacted performance.
That creates a fundamental disconnect. ACOs are accountable for outcomes in environments where visibility is still catching up to responsibility.
Reframing Fraud, Waste, and Abuse
Fraud, waste, and abuse are typically discussed through a compliance lens. While that perspective is important, it misses a larger opportunity. For ACOs, these issues are often signals of misalignment between clinical intent, care delivery, and financial measurement.
In practice, that misalignment can take several forms:
- Referral patterns that drift from evidence based pathways
- Utilization that does not consistently align with patient need
- Billing activity that does not fully reflect the care delivered
Without aligned data, these patterns are difficult to interpret. And when they are difficult to interpret, they are even harder to address in ways that improve outcomes rather than simply reduce cost.
ACOs Are Built to Solve This. But They Need Better Inputs.
ACOs are designed to connect care across settings. They bring together primary care, specialists, post acute providers, and community based services with the goal of creating a more coordinated experience for patients.
That model works—but only when it is supported by information that reflects the full picture.
To manage variation and improve consistency, organizations need access to data that is timely, structured, and usable. That includes visibility into utilization trends as they are emerging, not months after the fact, and the ability to connect activity across care settings rather than analyzing each piece in isolation.
When that level of insight is available, care teams can move from reacting to what has already happened to influencing what happens next. That shift is where coordination becomes proactive instead of retrospective.
From Detection to Understanding
The conversation in value based care is beginning to evolve beyond simply identifying outliers. The more important question is why those patterns exist and whether they are clinically appropriate.
Earlier insight into utilization trends allows organizations to distinguish between necessary variation and activity that does not contribute to improved outcomes. That distinction is critical, because not all variation is problematic and not all cost is waste.
The goal is not to eliminate utilization. It is to align it with better outcomes.
That level of understanding requires context, and context is only possible when data is connected and consistent across sources.
Reducing Administrative Friction Without Losing Rigor
Another benefit of better data alignment is operational clarity. When information is fragmented, teams spend significant time reconciling discrepancies, validating data, and trying to understand what is actually happening before they can take action.
When data is aligned, that friction decreases.
Care teams can focus less on verifying information and more on applying it. Decisions can be made more quickly and with greater confidence. Over time, that shift allows organizations to operate with both greater efficiency and greater precision.
Why This Matters More Than Ever
ACOs have already demonstrated that coordinated care models can reduce avoidable utilization and improve patient experience. Those outcomes are not theoretical. They are happening today.
Sustaining that success, however, depends on whether the infrastructure supporting these models reflects how care is actually delivered. Real world care does not happen in silos. It spans providers, settings, and time.
Data systems need to do the same.
Getting Closer to the Truth of Performance
At its core, the conversation around fraud, waste, and abuse is about accuracy. It is about ensuring that cost signals reflect actual care activity and that performance benchmarks align with clinical reality.
When that alignment is in place, organizations are better positioned to:
- Invest confidently in care management strategies
- Strengthen provider collaboration
- Engage more effectively with payer partners
- Build sustainable models for long term population health
Without it, even strong performance can be obscured by incomplete or inconsistent data.
The Role of Data Alignment in What Comes Next
Organizations operating in value based care are not just managing cost. They are shaping how care is delivered across the healthcare ecosystem.
They are working to create more consistent patient experiences, improve communication across care teams, and ensure that care is delivered at the appropriate time and in the appropriate setting.
Supporting those efforts requires more than incremental improvements. It requires a more intentional approach to how data is shared, interpreted, and applied.
As data becomes more connected and more actionable, ACOs are better equipped to do what they were designed to do: coordinate care in a way that improves outcomes while responsibly managing resources.
This Is Not Just About Oversight
Strengthening program integrity is often framed as tightening controls or increasing oversight. For ACOs, it is something more constructive.
It is about creating an environment where organizations have the clarity they need to succeed.
Because when you can clearly see how care is delivered, how it is utilized, and how it is measured, you are no longer managing in the dark. You are leading with insight.
Reference
National Association of ACOs. (2026). ACO Forum on Fraud, Waste, and Abuse [Webinar].
https://www.naacos.com/webinar-aco-forum-on-fraud-waste-abuse/
