A LOVE LETTER TO REGULATORS

Dearest Regulatory Agency Friends,

It’s been a while since we said HELLO! We love seeing many of you at industry conferences. We also recognize the critical role you play in fraud prevention! Acknowledging the challenges we all face in this complex ecosystem is something we’ve been thinking a lot about. So in the spirit of Valentine’s Day, we’ve decided to dedicate our annual love letter to you and provide some feedback that may help. Our experience in the healthcare fraud, waste and abuse (FWA) industry has given us a close up look at the difficulties encountered by regulators, MCOs and the industry vendors who support them. Some of us have quite literally been in your shoes. So we send you this message with hearts full of hope that you’ll find some good nuggets of information to help facilitate collaboration and efficiency in our shared goal of fighting healthcare fraud! Here we go!

Communication and Collaboration is Key (and Sometimes Missing!)

Have we mentioned that we’re all in this fight together? Please believe us when we say it! We would love nothing more than to stand side by side with you and fight fraud together! But in order to do that we need strong communication and collaboration. If you’ve been in the industry long enough, you’ve surely seen some great examples of this (e.g., remember New Hampshire's monthly meetings with MCOs and MFCU? That teamwork made the dream work - that's relationship goals right there!) and some not so good examples (e.g. MCO’s sending referrals over and then... crickets...).

There’s got to be a happy middle ground here.

We swoon when you build collaborative connections with stakeholders and bring us together. It makes everything smoother, from basic case discussions and workgroup meetings to requests for information and informed decision-making. Just let us be part of the conversation.

We know you have to issue memos, bulletins, and All Plan Letters, but sometimes we just need to have a simple conversation. Although it may be frustrating when we ask for clarification to those memos, letters, etc. it’s only because we want to do the right thing. We’re naturally inquisitive people! The ‘why’ often matters. But even if you can’t answer the ‘why’ please, please… don’t ghost us. Let’s have a conversation so we can give you what you actually need.

2. Resource Management & Reporting Requirements - Help Us Help You

Focusing on what’s truly important is a priority for all of us because frankly, we all are doing the best we can with the resources we have. We know you’re understaffed. We are too! Measuring our progress via reports and metrics is a necessary part of the job but we don’t understand why we need to measure things that aren’t reasonably related to our investigatory work. Investigators are naturally “why” people – we just need to understand the rationale behind it and when we do, we’re happy to provide it.

We respectfully request that before implementing new requirements, please consider the strain on both of our resources. We know many agencies abide by the "refer everything" principle that entails sharing anything that even smells like it could be FWA, but we’ve seen that go terribly awry. What adds even more complexity to that expectation is that we often have turnaround times that are unreasonable (we remember a ‘refer everything’ debacle years ago… the timelines for referrals were 3 and 7 days. How could any agency even review all of those referrals??)

3. Timelines and Expectations: Reality Check

We know you want results faster than a speeding bullet, but just like forming a loving partnership, good investigations take time. Demanding final investigation results in 30 days is like expecting a gourmet meal in 5 minutes. We need more realistic expectations. We cannot possibly deliver final investigation results if the investigation is still in the early stages 30 days in.

We want you to be successful and get these fraudsters. In order to help we just need:

Consistency. From state to state, Medicaid is like a box of chocolates – you never know what you're gonna get. A little consistency would be sweet. Many of us provide support for multiple states, so it makes things harder when we have a 5-day turnaround in one state and a 10-day turnaround in another.
Guidance. Please, make it clear what's a requirement and what's just a strong suggestion. That will help us with our internal workflows designed to meet your needs. We would adore it if this guidance was provided before we get audited and see it written as a corrective action in our final audit findings.🥰
Communication. See number 1 above.❣️

4. Advances in Technology… or Lack Thereof.

This is a big one to unpack. For the sake of this article, we’ll keep it short and sweet. We see a serious lack of innovation. We need you to embrace the future (or at least the present). Using some of your online portals can be super frustrating when they don’t work. Please invest in upgrading your systems so that the online portals don’t time out faster than a Tinder date and lose all of our data. It’s heartbreaking!

Oh, and we really think that having a budget for analytics platforms at the state levels should be required. There’s so much that you don’t get to see in the data because you’re understaffed and handling a million referrals from plans! If you invested in a strong analytics solution, you’d definitely get bigger bang for your buck and that will improve success across state and Federal agencies!

5. Training, Training, Training!

Training... where shall we begin? There’s general agreement that training is valuable across the board, whether it be mandatory training required by our regulatory friends or voluntary training provided by a plan. We love to be involved in this - either through collaboration or invitation. Mandating it of us without providing guidance about what you are expecting is frustrating.

We would also be remiss if we didn’t mention that your own analysts and investigators should be able to participate in more training. When we send over referrals (especially slam dunk ones) we love when the investigators have a strong understanding of the types of procedures, etc. so we can help strategize next steps. Whether that training comes from conferences or workgroup meetings really doesn’t matter.

You all are near and dear to us. We hope this has been helpful - let us know what you think! Until our next article, remember - we’ve got nothing but love for ya!

Integrity Advantage helps healthcare payers fight fraud, waste and abuse by providing consulting, investigation, medical review and other essential services that FWA and Compliance Programs need to succeed. 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.

A Love Letter to Regulators