Surviving in the world of FWA is somewhat like surviving in the wild. Without some essential elements, your shot at success decreases. Don’t go on the journey alone. Download our SIU Survival Guide and read about ten critical elements that you can implement to set up your FWA program for success. In it, we share tips and lessons learned from many years of hands-on experience working with payers of various sizes and different lines of business. Take our guide with you on your journey and reimagine the value of your FWA Program!

SIU Survival Guide

Ten Critical Elements You Need to Set Up Your FWA Program For Success

Introduction

One of our (ok maybe just Jala’s) favorite shows is the reality show, Survivor. If you’re a fan, you're happily watching Season 42 and grateful that it's back on! It often reminds us of the things that we all take for granted each day that we need to survive. Being successful at Survivor requires you to be able to make fire, build a shelter and find food. But it also requires you to compete at challenges - a lot of challenges. This got us thinking about the many challenges we face from an FWA program perspective. Specifically, what are some of the challenges you must overcome in order to set up your program for success?

This guide outlines ten areas that we have learned are some of the most critical elements needed to set your FWA program up for success. To cover all the ins-and-outs of SIU in this guide would make for a mammoth publication so we’ve tried to compile a guide with some key lessons we learned the hard way. We've focused on the areas that are often questioned, debated and essentially can apply to all plans no matter the maturity, size, geography or lines of business.

It goes without saying that every health plan has nuances that make them unique, so there are several things that are non-negotiable related to your regulatory landscape that we didn’t go into here. We know that you are aware of what those are. So, whether you take one lesson from this guide, or multiple, we hope you take a minute to let us know what you think of these 10 areas!

#1 - Create Structure and Processes

Setting up the foundation for success is imperative. We’d be remiss to launch into all the other areas without touching first on this. The FWA program structure and processes are partly dependent on your plan membership, team size, regulatory oversight, etc. but here are a few guidelines:

Structure your team to align with your business.

Know your claim types and spend so you can set up investigations and staff to correlate. For example, if 80% of your plan spend is medical, then 80% of your cases and staff should be focused on medical investigations. If the remaining 20% of your plan spend is pharmacy, you should expect your caseload / staff alignment to follow suit. Some SIU’s hire specialized investigators for dental, pharmacy, etc. but don’t always have the workload to support a full caseload for these staff. Do this if you’ve got the claims spend to support FTE’s that will only be focused on that line of business. If not, cross train your staff so they can handle these types of cases.

Consider separation of duties for efficiency.

If your investigators are responsible for managing the incoming complaints and referrals (triage), working cases (analysis and investigation) AND reviewing their own medical records, they may not be as efficient. We find that plans with staff who are focused on individual duties are more efficient as a team. Take for example, the medical review. A single medical record review can take a week or more if you have a decent sized sample, complete with determinations, research, code leveling, and a summary. If you are trying to manage a case load and review records, the start and stop might be too much. And there is also the question of whether or not you will introduce bias to the case. If you have the ability (based on the size of your team) to designate staff for each role, that might be the way to improve overall team efficiency.

Document Processes.

We know we sound like a broken record, but we are still shocked at how many FWA programs do not have a comprehensive policy & procedure (P&P) in place. This is literally one of the core foundational pieces of an FWA program. Now we know many regulators expect FWA Plans. This is not the same thing as a P&P. An FWA plan describes your company’s approach to fraud, waste and abuse detection and is typically an external facing document. P&P’s describe your particular standards and expectations of all FWA staff and is an internal document.

#2 - Never Stop Training

If you immediately think of the new hire, run of the mill, required training, stop right there. This is not what we mean. We are talking about hands-on training by the experts on your team, or in the industry, that have done the work - and done it well.

A good training program accomplishes two very important things:

• It provides an opportunity for professional growth for the ‘trainer’ in your department that is creating content and presenting

• It furthers the knowledge base for your team.

Making training a priority has been shown to improve team morale because it fosters a sense of comradery while clearly demonstrating that leadership sees the value investing in the team.

Your team probably has individuals that have become SMEs (subject matter experts) in certain areas, either out of necessity or desire. Often, we gravitate to things we enjoy, which creates ideal ‘trainers’ since their passion and enthusiasm will make both the training content and delivery that much better. Unfortunately, you may not have the internal staff who can conduct the needed training, in which case you may need to bring someone in or send your staff to outside trainings.

Don’t overthink it either, not all training needs to long and chock full of earth-shattering new ideas. So call out your introverted experts and energetic socialites for regularly scheduled training sessions!

#3 - Figure Out Your Recovery Appetite

Before you can do anything with investigative findings, you need to figure out what your organization's recovery appetite is.

Is your organization is focused on educating the provider before recoupment?

Or is pursuing the overpayment the first priority?

We’ve seen different ways of approaching this and they are typically based on the plan's preference. For example, some provider owned organizations are focused on the compliance and education aspect first and foremost. Conversely, we have seen companies that pursue the recovery first.

This is really important to figure out early on and can save you a lot of embarrassment and frustration later. It also can reduce provider abrasion significantly, which many companies prefer to do.

Keep in mind, regulatory agencies tend to weigh in on this matter so check your regs. Depending on which option you prioritize, it can affect annual ROI, vendor relationships and the SIU's ability to create specific goals that demonstrate their value.

#4 - Implement Effective Medical Record Reviews

We are shocked by the lack of discussion around the medical record reviews. It’s literally some of the most important evidence for our cases. Most investigations have records reviewed to determine whether the documentation supports the claims billed. And yet, it’s discussed less than other topics at conferences or webinars! A couple of important tips:

Define Your Conditions of Payment.

By conditions of payment, we mean the conditions you define as reasons for denial. There are many things that you can technically cite as improperly documented when it comes to complying with a code, policy or regulation. Each plan needs to make their own decisions on what constitutes a condition of payment, based on their appetite for denials and provider abrasion. Ultimately, every medical reviewer should have the same understanding of what is a condition of payment or denial reason. We’ve seen plans that vary vastly, and that’s ok... as long as it’s consistent. Make sure the team; medical reviewers, investigators, analysts, and leadership, are on the same page. The last thing you need is a great case with a sizable overpayment which took hours from the team, but doesn’t get support to pursue! Get ahead of this one. It will make record reviews and investigations significantly more efficient, as well as increase the confidence of the team in making determinations and talking to providers. For more info on conditions of payment, check out the article on our website about FWA and Conditions of Payment - Safeguarding the Integrity of Your Medical Record Review.

Set Up Collaboration Meetings.

There are many best practices for facilitating good communication within your team. We find that the medical review team tend to feel separated from the investigative team. Setting up regularly scheduled meetings where investigators can discuss the allegations of a case with the medical review staff, can help open those lines of communication. The group may discuss coding insights, procedural understanding or sampling design that can refute or substantiate an allegation. These can be scheduled as needed or as a regular standing meeting, but the key is to have them.

Consider Your Sampling Design.

For many medical review teams, sampling is not something they are typically involved in and for many, want nothing to do with. However, understanding that their review of an allegation may require the investigator to request records in a certain manner can make the difference between a strong case and one that is not easy to defend.

Jess' Lesson Learned:

"I remember an early case for a Physical Therapist for which I did my sample and was awaiting the medical review completion. When the reviewer was assigned, she reached out to tell me that she could not refute nor substantiate my allegation based on how I sampled. The allegation was that the provider was exhausting the benefit and each member didn’t need the full course the benefit allowed. Well, I didn’t sample by member, and therefore we couldn’t see the full course of treatment or improvement to assess whether they needed the full benefit or not. A collaboration meeting would have prevented this from occurring because I would have requested the proper sample of medical records that were needed for our team to make the proper determination based on the full documentation."

#5 - Know When to Hold ‘Em and When to Fold ‘Em

A common issue for most teams is knowing when jump into the rabbit hole, and when to close the case and move on. Knowing when to cut your losses is a really important part of the job, although not an easy one. There isn’t a perfect answer, because every case is different. We have seen a lot of success using a prioritization tool to help make these decisions. It’s typically used by the triage or intake team to decide whether a lead progresses to a case or whether it should be closed. Although commonly implemented at the beginning of the process, it can be applied to cases further into the investigative process as well to help investigators decide whether the case merits further investigation.

Given the complexity and peculiarities of each case and payer, it’s not a one size fits all. You may have a fancy tool to help with this, it may be built into your case management tool, or you can set up a simple excel spreadsheet. We typically factor in exposure, members impacted, severity of the allegation, source of complaint, evidence available, etc.

By using clear guidance, you can take out the human bias by giving clear scoring methodologies. This will ensure your team is on the same page and working the process consistently without spending too much time on a case that doesn’t warrant it.

Caution: Regulators generally don’t like when you decide to close a case simply due to the at-risk amount. This is why we recommend multiple factors be included in your scoring method and that you apply the method consistently across your cases.

#6 - Don't Hide From the Subject

If you are investigating a provider, you’re likely going to have to talk to them. It’s ok!

It always shocks us how many staff members are absolutely terrified of having a conversation with a provider, but they don’t hesitate to send an overpayment letter for $100K or more and accuse them of the F word (which is Fraud, in case you weren't sure).

Here's our advice: Don’t hide.

We find that you cannot fairly resolve an overpayment if you don’t have the gumption to speak to the subject of your investigation (or their attorney if they’ve retained representation). That said, it’s important to make sure you’ve got your ducks in a row – you’ve requested the info you need, considered all relevant evidence, done your interviews, had the medical records reviewed by experienced/certified staff and you’ve got your legal team’s support to have these conversations if and when the opportunity presents itself. It’s not personal, you are doing your job and protecting your members, so treat the call as such.

The bottom-line is don’t be afraid to talk to providers or subjects. Just prepare for the conversation. It will make things easier for everyone.

#7 - Capture What You Need To Report

Reporting is a challenge for everyone. We work in a highly regulated industry and the work is far from linear. Add to that the changing reporting guidelines, switching of case management and analytic platforms and constant coding updates - it’s easy to see why it takes a lot of work to get reports done right. We all get wrapped up in other priorities with the best intentions of taking great notes on what needs improvement in case management to make reporting easier. We tend to be so focused on getting regulatory reports out the door on-time that we relish in the moment that we can actually stop and breathe. But so often, after we finish the task, in this case getting the reports submitted, we have to quickly move on to the next urgent need... and all the notes we took and intentions we had to make those changes immediately are abandoned. If you notice areas where you have challenges with case tracking and you know what it needs to be improved or strengthened, track them and put the changes in motion right away.

Quick Tip:

We all know you can’t report on what you don’t capture. If you are implementing a new case management system, or updating a current application, make sure to have your required (internal or external) reports on hand. Work backwards from the reports to ensure you can easily capture most or all of the information you will need.

#8 - Break Down Silos and Collaborate

SIU teams are relatively isolated from rest the of the organization. Many feel as though they aren’t invited into conversations across departments or don’t feel that it’s our place to insert ourselves into other conversations. Whether it’s due to ‘protecting the casework’ or conflicting priorities, it’s an issue that must be overcome. An isolated SIU doesn’t have the opportunity to make the impact that a well-connected and involved SIU does. We look for loopholes and risks. Bringing this perspective to processes can mitigate serious risk, saving the organization a lot of time and money.

One area where you may want to consider inserting yourself is vendor management. Vendor relationships are typically owned by a particular department. For example, the relationship with your pharmacy benefit manager (PBM) may be owned by your Pharmacy team. Their focus may be on formulary and patient management and not necessarily compliance with fraud, waste and abuse, prevention, detection, and investigation efforts. That’s our job, and therefore we need to provide the insight necessary to protect the interest of the health plan.

#9 - Arm Your Team With Tools for Success

As you may have noticed, we are total suckers for efficiency and because we are vendor neutral, we’ve gotten to see many of the technology applications in the market.

Trying to manage all the facets of an SIU without the right tools creates more burden on the team. And by tools we are talking about analytical and case management capabilities. Excel is great - but you can easily spin your wheels with millions of lines in spreadsheets, even with the best pivot tables, macros and charts on the planet. Having the right applications can work wonders. Although good software can be expensive, if used correctly, it should pay for itself. Many software applications on the market today have several ‘types’ of tools in one, while others let you purchase each module separately. One thing is paramount, regardless of the technical solution you chose... bad data in, bad data out. Implementation should be a process that is taken seriously with the business team (you!) involved in the decision-making process.

So, which tools do you need? Depending on the type of organization you work for will depend on which is most valuable to you. We prefer them all but generally refer to them in following 4 buckets:

Analytics.

An analytic platform for healthcare FWA should ask the data questions, via rules, algorithms, machine learning, artificial intelligence, etc. then present outliers for review. (Of note, we believe prepay without post pay is a glorified claim editor. Therefore, I’m including both pre- and post-pay analytics together for this guide.) Furthermore, an analytic tool should have strong peer comparison capabilities, customizable thresholds, public records and great visuals. Flexible solutions that can score and assess data from varying perspectives (member, rendering provider, billing provider), across lines of business (commercial, Medicare, Medicaid, FEHB) and claim types (pharmacy, medical, dental, facility) are some of the best options out there. Its sounds like a lot, but there are many technology vendors doing really cool stuff!

Query.

An ad-hoc query tool or data warehouse should allow a flexible way to get claims, eligibility as well as member and provider data. It should house at least enough data to support your case look-back period, usually they can keep at least 3 years. While it’s great to be able to drill into the analytics for flags, there are many scenarios where an SIU may need to get at the data in a more flexible and robust way. Ideally, this tool would also have the ability to conduct some analysis to limit the results. What I mean is a basic query tool will allow me to pull out all medical and facility claims for Provider A. However, a robust tool with analysis capability, will allow me to pull all claims for Provider A when any member had a medical and a facility claim within 3 days of each other.

Case Management.

A basic case management tool is critical, but a great case management tool is... dare we say, life changing. Without a good way to track the day-to-day of investigative and medical review life, you can’t report it with any ease. If you want a compliant program, an efficient team and easy reporting, you need robust case management.

Things to keep in mind in assessing case management features in the market: flexibility to change drop down menus and add fields, integrated workflow, ability to track case notes, medical reviews, interdepartmental communication and financials. There’s also the tracking, reporting, and integration with existing analytics, attachment capabilities, roles and controls, the list goes on and on.

The overarching suggestion is to have your regulatory or required reports handy, write up the workflow of your department and expect to spend some time getting it right. It will be worth it!

Prepay.

As mentioned earlier, we lump prepay and post-pay together for analytics, which leaves an opportunity to discuss a separate prepay solution for managing the process. Prepay is the fastest way to make an impact on ROI. We all know stopping the claim is easier than chasing down overpayments. However, that doesn’t come without an administrative burden that requires a detailed and stringent process.

Consideration should be given to the integration with your analytics tool(s), case management, and maybe even your claims system, as well as timing, access and control. By control, we mean whether you can stop a claim only by CPT, member, provider, diagnosis, units, LOB, etc. You want flexibility with prepay. You do not want to jump in the deep end only to end up with appeals and provider abrasion.

#10 - Perform Periodic Check Ups

You’ve got the critical pieces in place...Yay! Now what? Everything is smooth sailing... relax and enjoy the ride? That sounds glorious, but unlikely!

The assumption that everything is perfect can backfire. The best FWA programs do periodic checkups to make sure they are on top of new schemes, they set up annual workplans and watch where risks to the company may pop up. Set some annual reminders to check up on:

1. Goals that challenge your team, make sure some revolve around using the tools. (For more on goal setting check out our article.)

2. Regularly updating your P&P's to ensure the whole team is on the same page.

3. Identifying new training opportunities for you and your team.

4. Forging stronger interdepartmental relationships.

5. Scheduling regular meetings with your tech vendor(s): What are they doing to make your FWA program more successful and efficient? Does their roadmap integrate things that you need from the tool?)

Wrap It All Up

FWA Programs have a lot going on. We couldn't cover everything here, but the purpose of this guide was to share what we feel are the essential lessons. And while we always set out to make these articles short, it never works! There’s so much to cover - much more than what we included here. Maybe a Part 2 is coming....?

If you've read this guide and you don’t have all of these components in place, don’t panic. This is just a guide and as we mentioned earlier, we understand that programs vary. One or more of these might hit a nerve because you’ve known it needs to be addressed. For some who are building a new program from scratch, this will serve as a roadmap. Take the time to consider these as you build your program and don't hesitate to reach out with any questions!