In an SIU, there may be pressure to identify cases that generate return on investment (ROI). It is important to remember that all cases have the potential to bring value to your SIU. In our latest article, we identify four perspectives on how a case with no recovery can bring value to your organization.

The Unexpected Value of a Case with No Recovery

If your FWA case process is similar to ours, you’ll likely put together a lead based on an allegation and determine if it’s suspicious enough to turn into a case. From there, you may request medical records for review to determine if services were billed and paid appropriately based on those medical records. But long before a case goes to review, investigators may be asked to answer difficult questions on potential return on investment (ROI). There are unicorn cases, of course, where we find a billing practice that is just flat-out wrong, and we can confidently predict the overpayment, but in the SIU, we usually can’t predict ROI until further along in a case.

Most FWA programs rely on recoveries and savings as the measure of success. But there is another critical component that can amount to big dollars: Prevented Loss.

Prevented loss refers to the potential financial damages avoided or mitigated due to proactive measures or interventions. In the context of investigations or risk management, prevented loss is the monetary loss that would have occurred if a harmful event or activity had not been detected and addressed in a timely manner. These include changes in behavior or process improvements that are a direct result of SIU involvement. An example of a change in behavior may be a change in billing pattern (think high level EMs or unbundling) or lack of billing all together. Similarly, a process improvement may include the implementation of a new policy that limits who or how a service is billed. Capturing prevented losses helps quantify the effectiveness of the SIU’s preventive measures and provides insights into the cost-saving impact of proactive risk management strategies. For reference, NHCAA published a white paper that outlines ROI and financial calculations.

What can we expect as the ROI for this case?

Deciding to move an investigation to the next stage may be a difficult conversation if you feel pressured to focus on recoveries. We’ve all faced the dreaded, sometimes difficult-to-answer question: what can we expect for the ROI? How do we respond? In truth, sometimes you can’t accurately and definitively answer this question before the case comes to a conclusion. When focusing solely on ROI, it can be easy to lose sight of the unexpected value of a case with no recovery. Consider the following ...

Identifying Claim Edit Gaps

During a routine healthcare investigation, it was discovered that claims were being processed incorrectly due to a malfunctioning claim edit. This prompted immediate action to improve the system's functionality and ensure claims were processed correctly. This one case highlighted the importance of regular monitoring and maintenance of healthcare technology systems to prevent errors and safeguard the integrity of payments. Updating the edit provided savings by denying claims being inappropriately billed, not only by the provider investigated, but all providers billing the impacted codes.

Provider Billing Validation

Recently a fraud, waste, and abuse investigation resulted in no findings. Meaning the investigation and record review resulted in only small educational components, rather than denying and recouping payments. Finding nothing inappropriate provides reassurance that the provider is billing accurately and ethically, which fosters trust between healthcare stakeholders. Investigative findings like this, albeit uncommon, protect against financial losses, uphold the reputation of the healthcare provider, and maintain the integrity of the broader healthcare system.

Patient Harm Protection

A healthcare investigation revealed that a provider was inappropriately prescribing mass quantities of opioids, posing a grave risk to patient safety. Swift action by the plan to inform the appropriate parties of misconduct prevented further harm to patients and potentially saved lives by halting the distribution of dangerous medications. Removing the provider from the network ensured that patients were no longer subjected to inappropriate opioid prescriptions, leading to improved healthcare outcomes and safeguarding against the devastating effects of opioid misuse and addiction.

Provider Manual Updates

It became evident during a series of investigations, that the plan’s provider manual did not thoroughly outline the FWA audit process, lookback period and recoupment guidelines. This discovery prompted a comprehensive review of the manual which revealed additional gaps. As a result, the provider manual was revised to include a number of suggestions such as a clearly defined appeals/ dispute process, recoupment capabilities, specific look back periods, usage of corrective action plans as well as alternate billing guidance in the absence of plan policy

Note:

If your organization maintains a strong emphasis on ROI recoveries, include these considerations in your upcoming discussions. Additionally, if prevented loss calculations are not currently integrated into your practices, it is recommended to incorporate them into any relevant scenarios. For further insights on this subject, we encourage you to consult the referenced papers in this article.

Wrap Up

The variety of cases that we are able to investigate can expose issues that other teams don’t typically see. This is one of the benefits of being healthcare fraud investigators and seeing claims after they have been adjudicated. We learn if claims edits are not functioning properly, the preauthorization process is missing something or providers are not billing appropriately. But our perspective also invites us to have productive conversation with other teams where our value is demonstrated in ways that are not recovery-based. Identifying areas in provider manuals that need refining or clarification may not be ‘measurable’ but it most certainly adds value. Investigations also serve to protect members and mitigate potential harm. So the next time you wonder how to demonstrate the value of a case with no recovery, keep this article in mind.

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.

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