Customization vs. Configuration in Healthcare Fraud Detection

Healthcare fraud schemes siphon away billions of dollars annually, with Medicare and Medicaid populations among the key targets. Estimates of healthcare fraud losses range from a conservative 3% of total annual healthcare expenditures to as high as 10%, potentially soaring to more than $300 billion per year. (Source: NHCAA, “The Challenge of Health Care Fraud”)

Unfortunately, when it comes to fraud mitigation, the question for states and program administrators isn’t, “should we?” but rather, “when and how?”

To bolster their fraud-detection capabilities, organizations may consider having a customized system built to their exact specifications. While this approach may sound good in theory — like having a suit custom-tailored — it can be pricey and significantly limit the ability to make major design changes.

The same applies for organizations embarking on an update to their fraud-detection capabilities. If you are weighing your options between a customized or configurable build, there are several important considerations as you compare and contrast. Let’s take a look at a customized build versus a configurable SaaS platform.

Customized Build: A Fixed Investment?

Of major importance is that a custom build will require a considerable amount of time — potentially two or more years — and significant expense to implement. This is especially pertinent for organizations facing time or budgetary constraints. Additional investments in time and money will be necessary if needs or requirements change down the line.

Another important consideration is the need for solid in-house expertise in system requirements and capabilities. This individual or team will be crucial to providing design concepts and heavily involved in testing the new fraud-detection system. Additionally, a customized build may not support new technological enhancements.

As one would imagine, cost is a major consideration when deciding between a customized build and a configurable platform. It is not uncommon for those who opt for a customized build to pay well over double the cost — even up to 10 times as much — as compared to a configurable platform. When costly change fees not accounted for in the original project budget are added in, the price goes even higher.

Configurable Platform: Built for Today and Tomorrow

Configurability offers significant advantages for states and healthcare organizations looking to take a more proactive approach to detecting fraud, waste and abuse. Modular, cloud-hosted platforms offer the flexibility to adapt to the ever-changing healthcare landscape and allow organizations to easily take advantage of new features as they become available.

Another major benefit of configurability is the cost. A configurable system is often a fraction of the cost of a customized build, both up front and over the long term. For example, a change in workflow may be necessary to accommodate a new approval process that involves additional steps. With most custom-built solutions, this would require new pricing and add to the existing budget. With a configurable solution, these changes come at no added expense.

Every organization’s needs are different, which makes having a high level of configurability especially valuable. Staying up to date on technology and even the latest fraud schemes is also easier with a configurable, agile platform that can accommodate new features, refreshed or emerging analytic models and other enhancements.

A Modern Approach to Combating Fraud

Gainwell Technologies’ Fraud Capture is a modular, cloud-based SaaS platform that is rigorously tested on a regular basis, ready for implementation and configurable to organizations’ evolving needs. Users can select their own settings, determine drop-down values, establish formats and templates for reporting and much more. Configuration changes can typically be made in less than two weeks — sometimes even the same day — at no additional cost.

With Fraud Capture, organizations gain the assurance of a skilled and knowledgeable group of anti-fraud professionals, funneling specific user needs and industry requirements to a dedicated IT engineering group. A wealth of experience and expertise is there to provide support.

Continuous Improvement

Among its many benefits, the Fraud Capture platform will not become “stale” and outdated. In fact, users can immediately take advantage of the latest system enhancements, and our team is currently working on several.

User feedback is incorporated into the system as appropriate, driving continuous improvement. Among those users are Gainwell’s expert Special Investigation Unit and Surveillance Utilization Review System team — specialists who ensure that tools and processes work smoothly and effectively, with minimal stakeholder disruption. Our hands-on use of the Fraud Capture solution adds a level of assurance that necessary changes and improvements will happen quickly and will be communicated to users.

A Strong Defense

When it comes to issues as complex and potentially costly as healthcare fraud, it makes sense to look for a proven and respected partner for guidance and support. With more than 50 years serving the public sector, Gainwell is the No. 1 Medicaid services provider, offering clients the innovation, reliability and flexible solutions they need to control costs, streamline processes and better serve their program members. To learn more, visit

The healthcare fraud landscape can be a difficult and opportunistic environment, with bad actors becoming increasingly knowledgeable about how Medicaid works — and how to work the system. With easy-to-use data exploration tools, clear data visualization and continuous system improvements, you can uncover fraud, capture savings and strengthen your defenses against a multi-billion-dollar healthcare problem.