Wasting Your Best Investigators
Most SIUs are reactive in nature. Taking time to hunt for cases based on the news, referrals, NHCAA trends, big-splash DOJ articles - investigators take that information and analyze their data to see if they have any sort of fraud exposure. That's really the nature of good law enforcement work - somebody tells you a piece of suspicious information or you happen to notice something, and then you go and investigate it. But, it’s easier said than done.
High output SIUs may do proactive, robust investigation using the advanced tools and broad resources that they have. But unfortunately, not all SIU teams have the best FWA prevention and detection tools or they lack the staff to do thorough investigations - let alone stay on top of more emerging and complex fraud cases.
As an investigator, how do you know the case you’re pursuing is truly the best use of your time? As an SIU leader, how do you know you’re running a high-impact, high-efficient team that’s not wasting time and energy pursuing small cases or hunting for the big ones?
Even the best SIUs are still using Excel. They're still running basic pivot tables to look for either aggregates or any outlier behavior. There's typically a pattern of different pivot tables that one would run - looking for highest billed procedure codes, highest billed diagnosis codes, date of service, or other key fields.
Opening a case can take a few weeks depending upon the maturity of the case and the size and infrastructure of the health plan. There are some plans where investigations operate like a JIRA request. They’ll put in a ticket or an e-mail with the data parameters that they're asking for, then it just goes in the queue. The SIU department may not get the insights they need for weeks after that initial request.
All too often investigators end up in this triage purgatory for far too long, trying to dig around and find the best things they can about this provider and whether they should open a case. Too much time is spent on trying to determine whether to open a case and for less experienced investigators, they may not be as well prepared for some schemes that they're hit with so that triage piece takes a lot of time and research. There is time wasted in data analysis and also in making internal requests. Some investigators don't have control over the data but they need all these other pieces that would truly help escalate that case. If you are the overseer of that department, a Director, an SIU Manager, you need to be cognizant of the time it’s taking your people to investigate a case and that is going to play into their individual performance and the performance of your unit. If an investigator is sitting on one lead for four months but hasn't officially opened a case, what the heck is going on?
The Wasted Cases
Here, case management becomes critical because you have to be able to track and report on the alerts and investigations that are going on. Once a lead is mature enough, or you have internal buy-in either from your manager, or maybe another department within the health plan, like network management, then you can officially transfer that to a case. Many health plans have pretty stringent guidelines on how long the case can be open, other deadlines associated with the case and guidelines that you have to follow to the letter.
With the extensive collaboration between departments in a health plan, the SIU really needs a single source to be able to track everything with a claim. For example, if you requested a contract on a provider from your network management team, you should be including that in your case file. In the event that something presents itself as more fraudulent than not and you have to turn everything over to a law enforcement agency, they will likely ask for a readout of your case. This would include case chronology, attachments, all your casework and notes involved with the case. Investigators just turn over what they have. There’s a lot of risk in submitting shoddy, disorganized casework last minute should the attorneys move forward with criminal proceedings. Attorneys won’t be able to recover costs with that low quality information that will surface in the discovery process.
Excel obviously isn't built for text heavy type of analytics and it was created for use with financial spreadsheets. So it gets messy and really ugly for those SIU still using Excel to track and update case material and activity.
Health plans invest a lot of money in fighting fraud and they may lose their case that they thought was viable, or even thought they could recover a portion of the money because of inconsistencies, procedural issues or a lack of investigative visibility. In fact, providers may then counter sue for things like harassment or may refuse to work with that plan’s patients again.
Wasted Prep Time for Audits and Compliance
Investigators like me, have certain generally accepted audit standards that we adhere to and a lot of that is about documentation, and documenting with clear, concise and accurate information. Picking up the pieces from a failed audit, or the stress of scrambling in preparation for one, is enough to emphasize the importance of organized case management.
When it comes to CMS and other regulatory audits, these organizations are going to make sure that health plans are meeting the standards to weed out fraud, waste and abuse. For example, in an audit you’ll get a request for a listing and report of all cases to date and then a random selection of cases will be chosen. For those select cases, SIUs need to have the best reporting and documentation for everything pertaining to each case and be able to export and submit all documentation in one simple package.
If a health plan fails any sort of audit, there are various levels of penalties. A health plan can get placed on a time-consuming, corrective action plan to get the SIU back up to compliance standards, they can lose funding for the MCO, or the CMS can fine the health plan depending upon the gravity of what was uncovered.
Eliminating the Waste With Case Management
The differences for the SIU in using Excel or Rules Based FWA detection versus Case Management with Advanced AI are innumerable. First and foremost, it's the workflow qualification which acts like a machine learning feedback loop but also helps to track investigative time frames. When the lead is first initiated and then transferred to a case, the decision trees throughout the workflow qualification process take the case to the next levels of approval, communication and follow up. Reminders can be set for team members for follow up on the case, or to review the data again and if there's not enough data at the time, it raises it to a higher, more appropriate level.
Activity timelines also come with proper Case Management tools too. You’re able to track and document those contemporaneous notes like what you did on a case with an opened alert, if you ran a query, or refreshed and changed any data on it. Shift’s Integrated Case Management has an audit trail to show who logged in, who touched the case and why it was updated. The activity timeline is really important because all notes are recorded and through those notes, you can track documents as well upload additional attachments. If you received a contract from network management and you read the contract, you can determine what sort of review scope you need.
Investigators should be using a Case Management system that is embedded in their alert system and not separate from it. Otherwise, you’re up against interoperability issues because those systems aren’t talking to each other and you may still have to export files which takes time. Having a Case Management system that is already integrated into the alert system allows the identified alert to kick off workflows and communications specific to that alert.
Having an Integrated Case Management tool allows all those small tasks that add up over time, to become offloaded and streamlined right in the platform. With a Case Management system, all that time is saved through detection and explanatory variables and all the rationale and decisions associated with a case. You can immediately start entering information on the case and have role based access and editing control across the team. All communication associated with the alert or case is all right there and an SIU doesn’t have to waste their time hunting down people and documents to move the case forward. It’s so much about immediate collaboration, visibility and documentation with Integrated Case Management.
Budgeting for advanced tools saves a lot of wasted time with resources and even saves money in the long run too. SIU teams won’t need to purchase a separate add on or find some other off the shelf solution. There is undeniable return on investment for health plans as the SIU is able to find, escalate and investigate in a fraction of the time. With a proper Case Management tool, alert detection algorithms and entity resolutions are fully integrated and leave no stone unturned - which saves investigators from many of those pre-investigative steps. At a bare minimum, case management increases the investigator’s efficiency and time spent on alerts because less time is spent on a particular task or building a certain contract. Integrated Case Management brings the most actionable recoverable alerts to the investigators.
Heads of SIU teams can also see who has the most cases or the most leads, they can see what that inventory is, they can see what the value is of one person's case over another. This can also justify somebody’s case specialization into one area over another like behavioral health over telehealth. Managers are able to better distribute workload, better understand the workload, better understand employee performance and how long it's taking them to do certain things.
What has traditionally been a very manual process with Case Management is now fully automated through Advanced AI and this frees up significant investigative time, increases accuracy and collaboration across the department and saves considerable money from FWA budgets. All data analysis is brought right into the UI and allows investigators to see all activity in real time, freeing them up from creating extra documentation and spreadsheets. Eliminating wasted time and resources, increasing time to value is critical for SIU teams and health plans. Integrated Case Management and Advanced AI allows for this level of immediate value from day one.
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