by Jala Attia

Back in the day, when I ran a health plan Special Investigations Unit (SIU), I used to think that outsourcing was a dirty word.  That word is often accompanied by fear, due to the cost cutting measures that the word outsourcing implies. So, when I was told my SIU was going to give outsourcing a shot, I had no choice but to try it.  It turns out, I hadn’t given it a fair shake.  In fact, I know many colleagues who have tried it and while they have mostly positive experiences, there are still lessons to be learned.  Here are 4 myths that we commonly hear about SIU outsourcing, key lessons learned, and quite frankly, how Integrity Advantage came to be.

Myth #1:  Positions will be eliminated.

By far, this is the #1 fear for most SIU leaders and teams. I was resistant when our executives proposed outsourcing SIU because I assumed that I’d have to eliminate positions and people from a team that I had invested so much into.  I thought I might end up with zero employees if I went the outsourced route. This actually was not the case – quite the opposite.  It wasn’t an all or nothing type of engagement, and most aren’t. It turns out that having even a fully outsourced SIU still has staff within the SIU. It’s necessary for the vendor’s success and as a result, the success of the SIU.

Outsourcing gave us the flexibility to have people provide support for the extra casework we didn’t have the staff and/or skillset to handle. When we no longer needed that support, the commitment ended there unless something else came up where we needed additional help. For example, when we needed medical review support, our vendor was able to provide a staff member with the skillset we needed, under the same contract. There was no commitment to a permanent employee and if, for some reason, we didn’t like the work those people provided, we asked the vendor to switch them out instead of having to performance manage an employee for months before they could be replaced.

Myth #2: Vendor services are ‘black box’; we’ll have no control.

A major concern about outsourcing involves a fear of the ‘black box’.  In this context, ‘black box’ refers to the lack of transparency into the events or steps taken when a vendor starts doing the work, before they return results.  My assumption was that we would not have control over the entire process or be able to see the step by step work being performed.  Why would I (a control-freak by nature) give up the control of my SIU to outsiders who didn’t understand the process we follow or the standards of quality I expected?

While there are some fraud, waste and abuse (FWA) market vendors whose services may still be considered ‘black box,’ health plans don’t have to accept this.  I certainly didn’t.  We insisted on setting expectations at the beginning of the engagement, and it became clear that not only were we able to see the work being performed, who was performing it and the outcome, but we also set all the standards we wanted followed.   A good vendor partner will prompt the discussion and get your input on all of these areas, well before work begins.

Myth #3: We already have the people and expertise we need.

When I looked at the work that needed to be done, most of it was centered on investigations.  I figured “my investigators can handle this.” But consider all the work that is routed through SIU: Data mining and analysis; investigations; statistical sampling; medical reviews; FWA appeals; provider discussions; internal FWA training; and law enforcement collaboration. The fact of the matter is that the expertise to do all this work varies and the sheer volume of cases may necessitate additional support. You might find yourself needing data analysts, investigators, certified coders, nurses and possibly physicians.  If you have an SIU of 5 or even 10 people, it’s unlikely that you can hire each of these roles separately within your existing budget.  Especially if you are a small health plan who has one or two staff in SIU and has regulatory obligations to detect, investigate and prevent fraud, waste and abuse.

Special projects and increased workloads don’t always conform neatly to an FTE model, whether by hours or skillset. Leveraging an outsourced SIU services vendor provides access to a variety of capabilities when you need them so that you don’t have to hire a full-time person for work that may not be consistent. Also, keep in mind that outsourced vendors have worked with a number of plans and have seen best practices as well as identified opportunities for improvement - all of which can be shared with you!

Myth #4: It’s too expensive. We can’t afford it!

I assumed that there was no way I could make an outsourced team fit into my budget.  I was wrong. When was the last time you took a look at the cost of hiring 1 full time employee for the SIU? Think about the experience, skills and the credentials you may be looking for, possibly within the confines of your geographic area.  Once you consider the cost of hiring, benefits, training, and certifications for your team, you quickly realize that skilled people can be expensive. Furthermore, for most plans, one FTE fills one particular role (e.g. investigations), not two or three (e.g. data analyst or Certified Professional Coder or medical record reviewer). 

Supplementing your SIU using outsourced services gives you to the flexibility to fill several roles by providing access to many skillsets for the price of one FTE.  Keep in mind that outsourced support tends to improve ROI through additional identification, investigation and prevention of FWA and, in the end, this option can be far more economical!

Light Bulb.

Short history lesson for those who are new to this industry: 

Around a decade ago, there was a big gap in the FWA industry. Most FWA vendors in the healthcare market sold technology capabilities but provided limited post-implementation support by way of services. These vendors began to realize the importance of providing additional support so that clients could get the most value from their technology.  Around this time, I was hired by a leading FWA technology vendor to build out a service capability in support of their technology. Over 7 years leading that program, we found it to be a great success. Having a services team to support clients improved FWA product sales, because it increased the value clients received from the tools while also significantly increasing the production of their SIU.

This revealed two critical areas of opportunity:

1)    The service offerings were limited to those plans that selected our technology solution. Those that did not couldn’t leverage our services.

2)    If an existing client switched solutions for any reason, which happens, they lost the service expertise and process continuity that we created to support their SIU.

Even with the build out and growth of service offerings, the focus was always development of the technology, first and foremost rather than investing in services.  The reason for this is simple math.  Human capital is far more expensive to maintain, and much less profitable than selling and maintaining a technology solution. So, the gap in the market still existed… Light Bulb!

Integrity Advantage.

This got me thinking that something better could be built. It must be built. A team that wasn’t influenced by technology. One where you only contract for what you need, when you need it; providing a more cost-effective option than hiring, maintaining, and firing staff. That alone is valuable. But consider the added value when you leverage the knowledge and perspective of outsourced staff:

-       Application of best practices gleaned from supporting a variety of health payers with different goals and appetites for pursuing recoveries

-       Familiarity with regulations and oversight of various lines of business such as Medicaid, Medicare, FEHBP, etc.

-       Insight into the geographic distribution of schemes

-       Experience with various technology solutions

-       Objectivity of providing support without obligation to any particular technology platform.  

We realized the number of vendor neutral companies with extensive healthcare fraud, waste and abuse experience, who have supported payers, as well as vendors, can be counted on one hand. We wanted to be part of that. And while there is no shortage of technology in the healthcare fraud market, our focus is on the people and the support organizations need.

That is how Integrity Advantage came to be.

The Bottom Line.

There are many myths that exist about SIU outsourcing. This article highlights the four most commonly heard throughout the industry. I hope this article helps provide a deeper understanding of the benefits of SIU outsourcing through dispelling these myths. By leveraging the perspective, value and flexibility offered by outsourced support, SIU’s have an efficient and cost-effective option available to them, regardless of which technology solution they choose.   

Integrity Advantage is a trusted advisor and independent services partner providing value and unbiased support to organizations. We provide healthcare fraud, waste and abuse (FWA) consulting, outsourced investigations and medical record review support for health payers and other organizations fighting healthcare fraud. We are a certified Women’s Business Enterprise (WBE) and an Economically Disadvantaged Woman Owned Small Business (EDWOSB).

For more information click below, call us at 866-644-7799 or email info@integrityadvantage.com.