When was the last time you took a step back to evaluate the effectiveness of your fraud, waste and abuse (FWA) program? A program assessment is an often-overlooked resource that enables you to gain new perspective by focusing on key areas to identify gaps and challenges that may be hindering you from achieving your goals. Read our updated whitepaper to glean valuable insights about how to conduct a program assessment and leverage it to formulate a plan-of-attack. We break it down into three focus areas so you can ask targeted questions to help you assess the true performance of your team. Use key action items to elevate your program to the next level.

A Clearer View of Your SIU

Key Action Items for Program Success

by Jala Attia, AHFI, CFE, CHC and Jessica Gay, CPC, AHFI, CFE

INTRODUCTION

In the world of healthcare fraud, waste and abuse (FWA) detection, prevention and investigations, Compliance, Payment Integrity and Special Investigations Unit (SIU) leaders often find themselves wondering how their team is performing with respect to the industry benchmarking. Yet with back-to-back meetings, managing staff and supporting organizational initiatives, finding the time to assess the team, develop and commit to long-term strategies for success feels like an impossible task.

If you can relate, you’re in good company! SIU and Compliance leaders around the country are expected to provide performance metrics to justify the existence of their team, in addition to cost-benefit analysis to hire more staff or improve technology capabilities. Despite the fact that many SIU’s have a regulatory mandate to exist, building and maintaining a successful SIU takes work.

There are two common extremes: checking the regulatory boxes for minimum compliance and success simply calculated by recoveries and savings. For most plans, their SIUs are somewhere in between. They are trying to juggle regulatory requirements, improve patient care, make the plan financially whole... and frankly, keep all the balls and competing priorities in the air! All the while, struggling to demonstrate their value and tie it to overall organizational objectives.

A program assessment can add immense value, perspective and provide a prioritized action plan to focus on areas of improvement.

WHAT IS A PROGRAM ASSESSMENT?

A program assessment evaluates how your organization’s fraud, waste and abuse (FWA) program is doing against a number of criteria and recommends improvements to close gaps or mitigate areas identified as risks. Industry benchmarks are just one way to look at performance, but with varying lines of business, claim types, membership, geography and other factors, benchmarks often need a footnote or interpretation to caveat how they apply to a particular plan. A program assessment focuses on requirements and benchmarks of your particular organization, by evaluating the people, process and technology within your FWA program..

BENEFITS OF A PROGRAM ASSESSMENT

Whether your goal is to better align with regulatory requirements or increase your productivity and results, a program assessment can reveal unknown issues that may be hindering success. Benefits include:

1) Identifying process gaps needing improvement

2) Gauging adequacy and effectiveness of the tools employed by the SIU

3) Evaluating staffing levels, composition and structure of the FWA team

4) A comprehensive, yet concise, report outlining findings and key areas of improvement

5) An itemized action-plan to improve focus, efficiency and performance of the program

PEOPLE, PROCESS & TECHNOLOGY

In order for your FWA program to be effective and successful, you have to have the right people, processes and technology in place. This might sound familiar as it’s a framework that's been in use for nearly 60 years when focusing on organizational transformation. These three elements are closely intertwined when creating a path to achieve exceptional outcomes.

Within each of the three main areas, the assessment is further broken down into current and future state. As you can imagine, the current state provides a look at the existing state of people, process and technology and should drive the recommendations for improvement. While the future state leverages industry best practices along with consideration of plan nuances, and the time and resources to execute a plan.

Throughout this process, we recommend keeping a running list and categorizing each of the gaps identified into similar buckets that can be put into an action plan for the execution.

PEOPLE

Maybe it goes without saying, you need the right team to drive the organization and unit to achieve its goals. The success of the team lies not only in experience, but also in the character, attitude and aptitude of the people that make it up. This is one of the most difficult parts of an assessment, yet we recommend this be the first area to tackle. Being able to objectively look at each team member, and the overall team, can present a challenge when you are the one who hired the team or created the structure. It’s even more difficult if you are too far removed from the day-to-day events occurring within the SIU. So, when approaching this aspect of the assessment, try to take a step back and look at it from an outsider's point of view.

We like to dive into a few key factors when evaluating the FWA team:

1. Structure and Size

Typically, you want to have your SIU structured to align to your book of business. Often, the main areas of a plans spend are those that will be most vulnerable to FWA. For example, if most of your claims spend is on medical claims, rather than pharmacy or dental, then the makeup of your team should mirror that. Also consider that the size of your team may need to comply with regulatory requirements. For instance, New Jersey’s MCO contract contains an investigator-to beneficiary ratio of 1 FTE for every 60,000 lives. While this is a fairly simple calculation, determining the number of managers, investigators, analysts, coders or nurses needed for the overall success of the unit is not as simple. It’s a balance that must take into account the number of investigations and record reviews initiated each year as well as internal processes that are followed to bring a case to closure.

2. Job Descriptions and Goals

This is an often-overlooked area. Holding people accountable is impossible without capturing the actual duties and expectations of individuals that make up the team. We commonly see job descriptions that are inconsistent with responsibilities, and goals that don't reflect the value the SIU is expected to provide. Managing expectations is infinitely easier if job descriptions and goals accurately capture responsibilities and performance requirements. SIU leadership should look at their goals as a measure of overall team performance and align the individual goals with the actual expectations of each role. Link responsibilities and annual objectives to team performance and you'll have individual contributors who understand what is expected of them and the value of their work to the organization.

3. Staff Composition and Experience

Based on your plan size, lines of business and claim distribution, you’ll need a variety of roles from skilled investigators to analysts and coders, to effectively manage FWA operations. In addition to making sure you have the right people in the right roles, the number of each will depend on the size of your team and all the factors we’ve discussed thus far. Frankly, with the right attitude and ability, you can teach almost anyone how to do a fraud investigation. We do it all the time! But you’ve got to have a few seasoned team members to provide guidance to less experienced staff in each of the roles.

People Key Action Items

• Structure your team by role to support your plan-specific business model, including lines of business, geographic location and types of claims, while keeping regulatory staffing in mind.

• Align individual expectations and contributions of each staff member to program success.

PROCESS

During the assessment of processes, a deep objective review extends beyond the SIU to assess interactions with the many areas of the organization your program touches. Focusing only on processes within the SIU doesn’t account for the fact that effective collaboration with other parts of the organization can significantly impact the ability of your team to efficiently perform their work. A process assessment should include interviews with personnel in legal, appeals, claims, call center, network and so on. You need a comprehensive evaluation of both areas and, as such, this component of the assessment often takes the most time.

1. Internal SIU Processes

Looking internally at processes within the SIU to support detection, investigation and prevention of fraud, waste or abuse is not as simple as having a policy and procedure manual in place. While documented policies and procedures are critical, the assessment should also incorporate many other day-to-day occurrences.

For example, how are new staff on-boarded and trained? How are incoming complaints handled and how quickly should they be reviewed? What is the process for identifying new cases for investigation? How is statistical sampling and extrapolation handled? Which processes are the team handling that are not typical SIU responsibilities? How is the prepay and post pay medical review team collaborating with the investigative staff?

This is the evaluation of the SIU process from A to Z and don't be surprised if it grows arms and legs. The stronger the processes that exist within SIU, the easier for staff to understand expectations and how SIU functions within the larger organization. We highly recommend that you document SIU processes for training purposes as well as overall guidance. Keep them updated and revisit them at least once per year to incorporate any changes.

2. Organizational Processes

As previously mentioned, the examination of internal SIU processes will cascade into other departments, identifying a number of touchpoints outside the SIU. These are the business units the SIU needs to work with regularly in order to operate effectively, as well as collaborate for the betterment of the organization and it's members.

For example, detailing the prepay review process may require support from claims and potentially education to customer service regarding how to handle member or provider inquiries about denied claims. While investigating a high prescriber of opioids, you may need to work with the pharmacy benefits manager (PBM), internal pharmacy team or utilization management to ensure that any quality of care or member harm issues are noted. To offset a provider's claims, you may need to work closely with your claims, recovery or legal teams.

You get the point. Identify other areas that intersect with SIU, outline the current process if it's working, improve it if it's not working or create a new one if it doesn't exist. Once you've identified a gap and worked to improve it, include it in the SIU policy and procedure document to provide a framework for training and continued collaboration.

Process Key Action Items

• Maintain a policy and procedure document that provides guidance to the SIU staff about any processes that involve SIU.

• Identify process touchpoints with other business units and evaluate the gaps and inefficiencies for improvement.

In the SIU we often uncover gaps in a variety of processes across the health plan. If not positioned correctly, this could be met with opposition or defensiveness. When you integrate, educate and motivate the enterprise behind the cause of fighting fraud, waste and abuse, you can significantly ease the barriers to cross-organizational success.

TECHNOLOGY

Often, the size and complexity of claims data at a health payer is just too much to sift through without the appropriate technology to quickly process mass quantities of data and identify outliers or schemes. Having the right tools for the job is imperative. Too many SIU’s are using systems that aren’t designed for healthcare fraud investigations and these systems make case management, data access and reporting very difficult. While health plans have internal applications such as claims systems, business intelligence tools and other capabilities, our focus is on SIU specific applications and whether they are driving value. SIU’s often have licensed applications in five key areas:

1. Analytics

A robust analytic solution will comb through millions of claim lines and identify outliers based on the review of what could seem like infinite data combinations. Historically, these are rules-based systems, yet most applications are using artificial intelligence (AI) to find what we don’t even know to look for with rules. Unfortunately, it’s common to work with a plan that either doesn’t use their licensed solution or finds very little value in its output. Is the tool appropriately configured to your plan’s specifications? Reach out to the analytics vendor and ask for more training, and more importantly, if the tool can provide value, link your team's goals to using it. If none of that works, it might be time to evaluate a new analytics tool.

2. Ad-Hoc Query Capabilities

Query capabilities enhance investigations by allowing investigators and analysts to drill down beyond summary data and gain further insight. Having a robust data warehouse query tool to ferret out the precise combination of codes suspected of abuse allows investigators to ask ‘questions’ of the data without needing to know SQL programming. Many plans have the ability to drill down into data using ad-hoc capabilities specifically designed for investigators, yet others don't think this functionality is as important. In our experience, most teams need this type of functionality, without it they struggle to efficiently gain access to claims and perform data analysis. Determine if these capabilities are available to you through your analytics vendor or in-house data team. If not, you may want to consider evaluating options on the market.

3. Case Management

In order to track and report all the work associated with an investigation; a case management application is critical. Regulatory oversight, the nature of a fraud case and the increasing number of data points for reporting make a case management system essential for efficient FWA program oversight. Many of the case management tools in the market can and should be customized to meet your particular needs. They should offer some level of customized and canned reports as well as dashboards that provide you with an easy way to see how your program is performing.

4. Coding Resources

Coding resources are valuable and not just for clinical / coding medical review teams. Investigators and analysts need to understand code definitions to identify billing issues and the clinical / coding team needs to take that understanding to the next level. Often these tools include resources for determining if the record is substantiated as billed and therefore in paramount in evaluating the evidence of an investigation. Arming your team with coding resources will provide them knowledge and confidence to make appropriate and accurate determinations during an investigation.

5. Public Records

During investigations, it’s important to be able to determine who a subject is, who they may be related to, what other entities they might own, any past convictions, etc. Choosing a reputable tool that pulls together information from open and closed sources will save a significant amount of time for your investigators. Keep in mind that some analytic solutions have public records capabilities built in. Most legal departments also use tools with public records capabilities. If you need a tool, consider asking them to add a license for SIU.

Technology Key Action Items:

• Determine if you are finding value in each of your existing SIU tools and, if not, consider reconfiguration or evaluating new options.

• If you evaluate new options, be mindful of what is a need versus a want; what you think is a ‘nice-to-have’ could actually be a need in order to reach your goals.

Now what? Ask yourself few questions to help decide whether an assessment is the right step for your plan.

1) Do you compile an annual FWA work plan or action plan that identifies areas to proactively evaluate?

2) Is each individual on your team aligned with business objectives and contributing to overall performance each year?

3) Is the SIU process streamlined and integrated into other departmental processes?

4) Can you easily capture critical performance metrics of your team?

5) Do SIU department and individual goals hold the team accountable for meeting SIU standards of performance?

6) Are you deriving the expected value from licensed detection, analysis and/or case management tools?

7) Do you have strong oversight of vendors / delegated entities related to fraud, waste and abuse efforts?

8) Do you perform an annual FWA risk assessment for your plan to identify areas of vulnerability in your business lines?

9) Are you confident that a regulatory audit would yield positive results regarding SIU processes and performance?

10) Is the value of your SIU or FWA program fully recognized at the enterprise level?

If you’ve answered no to many of these questions, it’s a good time to consider performing an assessment.

Sometimes the hardest part is finding the time and resources to get started. Should you need support in the assessment process or expert advice to assist in improving your FWA program that yield results beyond recoveries and savings, we can help. Our experience with dozens of FWA programs across the country has allowed us to share best practices and apply our industry knowledge to gain organizational buy in and present comprehensive, prioritized action plans for execution.

With more than 50 years of experience supporting payers, the Integrity Advantage team provides healthcare fraud, waste and abuse consulting, outsourced investigations and medical record reviews for Special Investigations Units and program integrity entities. We are certified as a Women’s Business Enterprise (WBE) and an Economically Disadvantaged Woman Owned Small Business (EDWOSB).

Integrity Advantage is the way healthcare payers reimagine the value of their fraud, waste and abuse program. We provide FWA services to payers around the country.

If you need a program assessment, program growth strategy, investigations, medical reviews or training support -- reach out today.

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.