As COVID-19 has rocked the foundation of our daily lives, it has also jolted Special Investigations Units (SIU) across the country. Why? Because many teams were already juggling full caseloads even before the pandemic began.  In some organizations, the lack of analytic capabilities inhibits the detection of new and emerging fraud schemes.

Although we are supporting clients with their COVID-19 strategy, you need to be able to analyze mass quantities of data in order to execute. Without the right tools, healthcare claims are simply too voluminous and complex to efficiently combat fraud, waste and abuse (FWA).  

Now more than ever, many organizations are recognizing the need for a strong technology solution to stay ahead of FWA.  If you don’t have one or are looking for a new one, consider your options.  Let’s be clear, we aren’t here trying to sell you a technology solution.  In fact, people are often surprised that we don’t have technology solutions to sell.  It’s not that we don’t see tremendous value in them, because we do! But the needs of all organizations are not the same.  Which is, in fact, why we are not tied to a tech platform - because we do see such value in many of the tools and capabilities in the FWA market.

As we talk with clients, one theme continues to surface:  the healthcare FWA industry is saturated with technology solutions. The list of organizations who offer anti-fraud technology is vast and leaders have used the term “vendor fatigue” to describe the process of selecting a new vendor.  The selection and implementation process is not just overwhelming, but also time consuming.  Payment integrity, compliance and SIU leaders who are not plugged in to the day to day operations of the SIU must make decisions based on price comparison, word of mouth or what is shown during a sales demo.  Because these contracts typically last for 3 – 5 years and are associated with significant license, hosting and implementation costs, making the right decision is critical. Furthermore, organizations tend to underestimate the amount of time away from their ‘real jobs’ the process will take. SIU staff who are already inundated with work, have neither the bandwidth nor the specialized knowledge to appropriately support implementation. This pertains to analytics and case management applications alike.

Consider engaging a consulting firm to help. But keep in mind, not all consulting firms are the same.  Before you embark on a quest for the right FWA tools, find a consulting partner with these 3 key characteristics:

1) No Strings Attached. Some consulting organizations in the FWA market today are tied to technology solutions or are otherwise paid for referrals.  This relationship may not align with your goals and may impede the firm’s ability to offer a truly unbiased view. Having an objective and educated perspective is crucial.  You want to look for a tech-agnostic firm, and by “tech-agnostic” we are talking about a consultant that is not compensated for referrals/sales.

Integrity Advantage provides an independent, objective, and unbiased perspective without incentive to sell a particular tool. Because we know every organization is different, our approach focuses on your key requirements, budget, time frame, and long-term goals. We truly value technology in the fight against FWA and are not compensated for referring or recommending any solutions to our clients. 

2) Breadth of Specialized Experience.  If you need brain surgery, you don’t go to a general practitioner who claims they can do it, you’d go to a specialist who’s performed many brain surgeries successfully before. Similarly, specialized experience in this field is key to success and it comes down to feet-on-the-street skills in healthcare fraud, waste and abuse investigation, analytics, case management as well as program oversight responsibilities.  Medicaid, Medicare, Federal Employee Health Benefits (FEHB) and other lines of business that exist in the market today are accompanied by a number of detection, prevention and reporting obligations.   Payers need to consider these during the selection and implementation process to ensure these obligations are successfully measured and reported.

Integrity Advantage has in-depth understanding of health plan operations and investigations because our team has many years of health payer experience.   Our team has quite literally been in your shoes and understands that selecting the right FWA solution is an investment that is critical to achieving your goals for years to come.  Since we are familiar with many of the solutions that are currently on the market, we can provide advice to help you understand capabilities that suit your needs.

 3) Focus on Customization. Healthcare data is messy.  If you’ve been involved with implementations before, you know that each health plan requires different levels of customization within the technology applications it chooses to use for fraud, waste and abuse detection and prevention efforts. Many of the solutions on the market today vary in flexibility and the level of customization afforded. Key considerations include the lines of business, complexity of the data and other nuances of your business. But what many plans don’t consider is that the process of implementing and customizing a new solution takes significant time and laser focus on the end user.  To understand how the application will be used is absolutely essential to achieving efficiency and value.

Leveraging our experience within the technology vendor community, we are acutely aware of the importance of the end user.  You won’t find a consulting firm in the market that is more in tune with the end user, because we’ve spent a considerable amount of time as the end user and supporting user-centric implementations. You can lean on us for support through the Request for Proposal (RFP) process, performing a competitive analysis of solutions available, and ultimately implementing the best solution for you.

Partnering with the right consultant is a tremendous help when selecting and implementing a fraud, waste and abuse technology solution to stay on top of new or existing schemes.  Trust Integrity Advantage to provide guidance and support to help you maneuver through the maze of options to meet your needs. To start a conversation, click below.