Misconceptions of SIU Outsourcing (REVISED)
Outsourcing is often thought to be a dirty word. But don’t be fooled - outsourcing can be a cost effective, high impact investment into the success of your team. Since many of you know this is precisely the business we are in - we decided to discuss some common misconceptions we’ve heard over the years and how it adds value to your overall FWA program.
Misconception #1: You’ll lose positions on your team… or your whole team.
By far, this is the #1 misconception for most SIU leaders and their teams. Executives tend to freak out their management team by suggesting outsourcing, because management immediately thinks they will end up with zero employees if they outsource anything. This actually is not the case – it’s quite the opposite. Outsourcing is not an all or nothing type of engagement. In fact, even fully outsourced engagements do not work without the health plan having staff who can support the vendor.
How it Adds Value: Outsourcing allows the flexibility to have people provide support for the extra or specialized work you don’t have the staff or skillset to handle. If you no longer need that support, the commitment ends there unless additional work or projects come up. It’s not uncommon for our support efforts to allow for the ebbs and flows both in volume and skillset needs. We can often provide support for medical review, data analysis and investigations, all under the same statement of work.
Misconception #2: My team already has the people and expertise needed.
Depending on the size of your plan, consider all the work that is routed through your SIU: Data mining and analysis; investigations; statistical sampling; medical reviews; FWA appeals; provider discussions; internal FWA training; and law enforcement collaboration. You may find that although you have investigators to work backlogged cases, you still need to find new quality investigations, complete medical reviews and appeals more quickly or even work on a special project. You might find yourself needing data analysts, investigators, certified coders, nurses and possibly physicians.
Would you hire all of these skillsets separately? Or would it make more sense to outsource some of this to a vendor who can provide all of those skillsets under a pricing arrangement that allows for you to get what you need, when you need it?
How it Adds Value: Understanding your workload and bottlenecks are one thing but knowing how to lessen your struggle AND take productivity to the next level is where the magic happens. The expertise and sheer volume to do all of this work varies and may necessitate additional support, either short or long term. But by exploring outsourced support options, you extend and broaden the expertise on your team. You increase your identified losses, recoveries, savings and prevented losses by leveraging an external perspective that can help you efficiently increase productivity.
Misconception #3: You’ll have zero control over the vendor.
A major concern about outsourcing involves fear of the lack of transparency into the events and steps taken when a vendor starts doing work, before they return results to you. A typical assumption is that when you outsource, you lose control over the entire process and/or lose sight of the step-by-step work being performed. There should be a contractual expectation that your vendor will conform to your particular standards and processes. Some of the expectations may be related to compliance and depend on the lines of business in play.
How it Adds Value: We’ve found that many small to mid-sized plans actually prefer if the vendor brings forward best practices gleaned from working with many other plans. For example, our experience has allowed us to create processes and templates that have been refined over the years. These can make your FWA program more streamlined and efficient. Health Plans have absolutely every right to expect to maintain as much or as little control as they would like. But it can be an easy improvement to benefit from what has worked well for others too!
Misconception #4: Waaaay too pricey!
There’s never an easy way to talk money. As we’ve discussed, the flexibility in how and what you outsource drives the cost. You can start small or jump in the deep end, but even a small budget can bring more value than expected. 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 (and that’s assuming you make the right hire the first time!)
How it Adds Value: Expanding your FWA program using outsourced services gives you to the flexibility to fill several roles by providing access to many skillsets for the price of one (or part 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 save you tons of money, far outweighing the cost of hiring support in the first place.
In Summary.
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.
Understanding of 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.
Third party, unbiased perspectives to help identify risks to the organization and make suggestions for improvement.
Objective support without obligation to any particular technology platform.
There are many misconceptions surrounding SIU outsourcing. This article highlights the four most commonly heard over years in this industry and how the reality of each has the potential to significantly increase value found within your FWA program. By leveraging the perspective, value and flexibility offered by outsourced support, FWA teams have an efficient and cost-effective option available, regardless of which technology solution they choose.
Integrity Advantage is the way healthcare payers reimagine the value of their fraud, waste and abuse program. Our unmatched expertise stems from decades of experience supporting dozens of organizations just like yours. Our experience providing consulting, investigative and medical review support to plans across all lines of business, geographical regions, and varying enterprise priorities give our clients a tremendous advantage. As a vendor-neutral partner, we are a trusted advisor, providing objective perspectives and offering solutions for real challenges faced by the payment integrity industry.
For more information, call us at 866-644-7799 or email info@integrityadvantage.com.