The Tie Between Compliance and FWA
For many small to mid-sized health plans, the Special Investigations Unit (SIU) or FWA Program reports to a Compliance executive. In those situations, it can sometimes be a challenge to prioritize meeting the many SIU objectives and responsibilities, in addition to health plans compliance needs. That’s why we use the analogy that meeting compliance requirements is getting to ‘base camp’ - but you should set your sights on climbing higher. Understanding your organizational profile, performing a risk assessment and identifying key goals will keep everyone on the path to FWA program success!
The Tie Between Compliance and FWA
For many small to mid-sized health plans, the Special Investigations Unit (SIU) or FWA Program reports to a Compliance executive. In those situations, it can sometimes be a challenge to prioritize meeting the many SIU objectives and responsibilities, in addition to health plans compliance needs. That’s why we use the analogy that meeting compliance requirements is getting to ‘base camp’ - but you should set your sights on climbing higher. Understanding your organizational profile, performing a risk assessment and identifying key goals will keep everyone on the path to FWA program success!
Think of “Compliance” as Base Camp
When it comes to compliance, there are many layers and levels that intertwine to make a health plan fully compliant. However, meeting basic compliance requirements does not mean the fraud, waste, and abuse (FWA) program is successful. Typically, there are a number of other areas that must be addressed and managed. Compliance is the baseline (or base camp) for a successful FWA program. Once all compliance elements are met, the fun begins! Teams can then prioritize other components that are part of the day-to-day FWA work, like:
Outlining key performance indicators
Streamlining policies
Performing proactive investigations
Benchmarking against industry best practices
These are just a few efforts that maximize program success and return on investment. Getting to base camp at Mt. Everest is a huge accomplishment; we think of that as being compliant. Once you get there, don’t stop! Continue climbing to the top!
In Case You Missed It
Our President, Jala Attia, discusses how Integrity Advantage envisions compliance and the critical other pieces of the puzzle that need to be considered in this short video: https://www.integrityadvantage.com/articles/fwa-program-pitfalls-2
Want to Achieve FWA Program Success?
1.Figure Out Your Organizational Objectives and Aggressiveness Profile.
Once you’ve met your compliance requirements, here are 5 foundational steps to building your FWA program to reach the summit: What is your organizational objective? Do you have buy in? What is your risk profile based on your lines of business, regulatory framework and geographic footprint? How aggressive does your plan tend to be? What resources do you have at your disposal?
2. Perform a Risk Assessment.
A risk assessment for FWA is an inventory and analysis of potential FWA risks which can help with devising awork plan for the year. This process will require you to identify risks, assess your internal controls and processes, and evaluate your exposure to these risks.
3. Develop an Investigative Team.
Remember, an FWA investigation is not the same thing as a compliance review. Investigations need certain skillsets to ensure thorough and accurate investigations. You should have policies and procedures, an effective triage process, detection capabilities and a whole lot more. Whether you outsource the function or have an in house team-this step is critical.
4. Monitor and Communicate Results.
Making informed decisions requires identifying key performance indicators, measuring them and effectively communicating results to stakeholders. It’s one of the easiest ways to get buy-in. Have the conversation!
5. Reassess and Adjust.
This is not a set it and forget it type of thing. You want to review and look at what was learned. What new initiatives emerged? What could have better prepared you this year? Plan to make next year stronger by adjusting your approach. YOU CAN START TODAY.
FWA programs need expert support. Let us help you hit the mark!
Building a compliant fraud, waste, and abuse program is about more than just being compliant. You need a team skilled in identifying, investigating, and preventing healthcare FWA. Integrity Advantage experts help develop robust FWA programs and elevate compliance programs.
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.