Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
KevinMD
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking
KevinMD
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking
  • About KevinMD | Kevin Pho, MD
  • Be heard on social media’s leading physician voice
  • Contact Kevin
  • Discounted enhanced author page
  • DMCA Policy
  • Establishing, Managing, and Protecting Your Online Reputation: A Social Media Guide for Physicians and Medical Practices
  • Group vs. individual disability insurance for doctors: pros and cons
  • KevinMD influencer opportunities
  • Opinion and commentary by KevinMD
  • Physician burnout speakers to keynote your conference
  • Physician Coaching by KevinMD
  • Physician keynote speaker: Kevin Pho, MD
  • Physician Speaking by KevinMD: a boutique speakers bureau
  • Primary care physician in Nashua, NH | Kevin Pho, MD
  • Privacy Policy
  • Recommended services by KevinMD
  • Terms of Use Agreement
  • Thank you for subscribing to KevinMD
  • Thank you for upgrading to the KevinMD enhanced author page
  • The biggest mistake doctors make when purchasing disability insurance
  • The doctor’s guide to disability insurance: short-term vs. long-term
  • The KevinMD ToolKit
  • Upgrade to the KevinMD enhanced author page
  • Why own-occupation disability insurance is a must for doctors

Why health care fraud detection requires payment integrity alignment

Tiffiny Black, DM, MPA, MBA
Policy
April 24, 2026
Share
Tweet
Share

In one health care organization, a provider was reviewed and cleared through routine payment integrity processes. Months later, that same provider became the subject of a fraud investigation, based on patterns that had been present all along. Both reviews were technically correct within their scope. But together, they revealed something more concerning: The system itself was not aligned. Health care organizations invest heavily in payment integrity (PI) and special investigations units (SIU) to detect improper payments, investigate fraud, and protect financial resources. These functions are designed to serve as safeguards within increasingly complex reimbursement systems. Yet despite these investments, many organizations continue to experience recurring provider issues, rising investigative workloads, and persistent financial leakage. The problem is often framed as one of fraud sophistication or insufficient detection. But that framing misses something more fundamental. By the time fraud is detected, the system has already failed.

Payment integrity and SIU operate with a shared mission but different orientations. PI focuses on transactional accuracy, reviewing claims, validating coding, and correcting payments. SIU focuses on provider behavior, identifying patterns, intent, and potential fraud. In theory, these functions should reinforce one another. In practice, they often operate in parallel. This creates a critical risk: The same provider or billing pattern may be reviewed by both functions, yet produce different conclusions. One team may determine that documentation supports billed services, while another later identifies concerning patterns such as cloned records or systematic overbilling. Both conclusions can be technically correct within their respective scopes. But together, they reveal a deeper issue: The organization is operating with competing versions of reality.

This is not simply a communication problem. It is a structural misalignment. Corrective action plans (CAPs) are intended to address identified issues and prevent recurrence. However, in many cases, CAPs are embedded in settlement agreements, minimally defined, and rarely monitored over time. Once funds are recovered, follow-up often gives way to new case demands. Providers may reappear months later, sometimes using different codes, but engaging in similar behavior. In this context, corrective action becomes less about sustained change and more about case closure.

Another driver of misalignment is incentive structure. Payment integrity teams are often measured on payment accuracy and cost containment, while SIU teams are measured on investigations and referrals. Each function may perform well against its own metrics, but those metrics do not always reinforce shared outcomes. Without aligned incentives, collaboration becomes situational rather than systemic. Organizations that demonstrate stronger alignment often establish shared, enterprise-level goals, such as medical cost reduction, that require cross-functional contribution. When multiple teams are accountable to a common outcome, coordination becomes necessary rather than optional. Volume also plays a role. High case loads, often hundreds per year, create pressure to resolve quickly, recover funds, and move forward. Under these conditions, long-term monitoring and follow-through become difficult to sustain. As a result, organizations may repeatedly address symptoms without resolving underlying causes.

A less visible but equally important factor is internal system design. Improper payments are not always driven by intentional fraud. They often result from incomplete policies, outdated coding frameworks, or configuration gaps that allow claims to pass incorrectly. In these cases, investigative functions are left to correct issues that could have been prevented upstream. This points to a broader reality: Fraud detection is often compensating for design failure. The dominant question in many organizations is how to detect fraud faster. A more effective question may be: What conditions allowed misalignment to persist long enough to become behavior?

Shifting the focus from detection to alignment changes how organizations approach integrity.

  • Fraud is visible. Misalignment is not.
  • Fraud is investigated. Misalignment is often normalized.
  • Fraud is treated as an event. Misalignment is a condition.
  • Fraud is not the first failure. Misalignment is.

Until organizations address the structural, behavioral, and incentive-based conditions that allow misalignment to take hold, integrity functions will remain reactive, identifying issues only after they have materialized. The future of program integrity will not be defined by stronger investigations alone, but by better system design, aligned incentives, and sustained accountability.

Tiffiny Black is a health care consultant.

Prev

The hidden dangers of dental sedation and dental anesthesia in kids

April 24, 2026 Kevin 0
…

Kevin

Tagged as: Practice Management

< Previous Post
The hidden dangers of dental sedation and dental anesthesia in kids

ADVERTISEMENT

More by Tiffiny Black, DM, MPA, MBA

  • Recognizing structural drift and institutional failure in health care

    Tiffiny Black, DM, MPA, MBA
  • Why implementation is not the same as readiness in health care

    Tiffiny Black, DM, MPA, MBA
  • Systemic failure in professional environments: the myth of protection

    Tiffiny Black, DM, MPA, MBA

Related Posts

  • Why the health care industry must prioritize health equity

    George T. Mathew, MD, MBA
  • Bridging the rural surgical care gap with rotating health care teams

    Ankit Jain
  • What happened to real care in health care?

    Christopher H. Foster, PhD, MPA
  • To “fix” health care delivery, turn to a value-based health care system

    David Bernstein, MD, MBA
  • Health care’s hidden problem: hospital primary care losses

    Christopher Habig, MBA
  • Melting the iron triangle: Prioritizing health equity in dynamic, innovative health care landscapes

    Nina Cloven, MHA

More in Policy

  • Preparing for Medicaid cuts and the imperial health boomerang

    MarkAlain Dery, DO, MPH
  • Physician-owned hospitals get a narrow CMS opening

    Dana Y. Lujan, MBA
  • Evaluating the credibility of major medical journals today

    Laurel A. Coons, PhD
  • How rural health care access impacts maternal mortality

    Alyssa Sterner
  • The hidden toll of medical debt on patient health and survival

    Adam Cunningham
  • How health care lobbying distorts the U.S. opioid crisis

    Richard A. Lawhern, PhD
  • Most Popular

  • Past Week

    • When shared decision making gives way to medical paternalism

      DeAnna Pollock, MD | Physician
    • How xenotransplantation could finally solve organ shortages

      Rafael S. Garcia-Cortes, MD | Conditions
    • Clinicians are failing at value-based care because no one taught them the system [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why health care fraud detection requires payment integrity alignment

      Tiffiny Black, DM, MPA, MBA | Policy
    • What to expect at your first gynecologic visit

      Callia Georgoulis | Conditions
    • Why current solutions to physician burnout are failing

      Bill Pressey | Conditions
  • Past 6 Months

    • Why clinicians fail at writing expert reports

      Tracy Liberatore, Esq, PA | Conditions
    • Rethinking the role of family physicians vs. specialists

      Ronald L. Lindsay, MD | Physician
    • Why clinical listening skills outpace artificial intelligence

      Ryan Egeland, MD, PhD | Tech
    • Why Florida physician background checks are driving doctors away

      Tamzin A. Rosenwasser, MD | Physician
    • Why we need a new medical specialty to fix corporate medicine

      Allan Dobzyniak, MD | Physician
    • The hidden clinical cost of HCC coding in primary care

      Jeffrey H. Millstein, MD | Physician
  • Recent Posts

    • Why health care fraud detection requires payment integrity alignment

      Tiffiny Black, DM, MPA, MBA | Policy
    • The hidden dangers of dental sedation and dental anesthesia in kids

      Irim Salik, MD | Conditions
    • What a tiny dog taught me about the nervous system

      Carrie Friedman, NP | Conditions
    • 5 patterns behind health care startups that fail

      Harsha Moole, MD | Finance
    • Rethinking nutrition policy on ultra-processed food

      Hana Kahleova, MD, PhD | Conditions
    • Preparing for Medicaid cuts and the imperial health boomerang

      MarkAlain Dery, DO, MPH | Policy

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

Leave a Comment

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

  • Most Popular

  • Past Week

    • When shared decision making gives way to medical paternalism

      DeAnna Pollock, MD | Physician
    • How xenotransplantation could finally solve organ shortages

      Rafael S. Garcia-Cortes, MD | Conditions
    • Clinicians are failing at value-based care because no one taught them the system [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why health care fraud detection requires payment integrity alignment

      Tiffiny Black, DM, MPA, MBA | Policy
    • What to expect at your first gynecologic visit

      Callia Georgoulis | Conditions
    • Why current solutions to physician burnout are failing

      Bill Pressey | Conditions
  • Past 6 Months

    • Why clinicians fail at writing expert reports

      Tracy Liberatore, Esq, PA | Conditions
    • Rethinking the role of family physicians vs. specialists

      Ronald L. Lindsay, MD | Physician
    • Why clinical listening skills outpace artificial intelligence

      Ryan Egeland, MD, PhD | Tech
    • Why Florida physician background checks are driving doctors away

      Tamzin A. Rosenwasser, MD | Physician
    • Why we need a new medical specialty to fix corporate medicine

      Allan Dobzyniak, MD | Physician
    • The hidden clinical cost of HCC coding in primary care

      Jeffrey H. Millstein, MD | Physician
  • Recent Posts

    • Why health care fraud detection requires payment integrity alignment

      Tiffiny Black, DM, MPA, MBA | Policy
    • The hidden dangers of dental sedation and dental anesthesia in kids

      Irim Salik, MD | Conditions
    • What a tiny dog taught me about the nervous system

      Carrie Friedman, NP | Conditions
    • 5 patterns behind health care startups that fail

      Harsha Moole, MD | Finance
    • Rethinking nutrition policy on ultra-processed food

      Hana Kahleova, MD, PhD | Conditions
    • Preparing for Medicaid cuts and the imperial health boomerang

      MarkAlain Dery, DO, MPH | Policy

MedPage Today Professional

An Everyday Health Property Medpage Today

Copyright © 2026 KevinMD.com | Powered by Astra WordPress Theme

  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Leave a Comment

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...