Amid growing federal scrutiny of healthcare fraud, it’s critical to distinguish intentional fraud from unintentional payment errors. In FY2024, CMS reported over $86 billion in improper payments, primarily due to overpayments. This underscores the importance of payment integrity (PI) which helps detect and prevent waste — not fraud — by ensuring claims are paid accurately. To drive better outcomes, it's essential to distinguish between fraud, waste and abuse (FWA) and understand where PI fits in.

Defining FWA — and where PI lives

Fraud is intentional deception for financial gain, typically investigated by Special Investigation Units (SIUs); you may also hear "program integrity" associated with fraud.

Abuse involves questionable billing practices that may not be fraudulent but could be e

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