5 steps for preventing fraud and abuse

Much has been written and discussed lately about the best way to go about preventing fraud, waste and abuse in the health care industry. Implementing better technology and processes to get payments right the first time and reducing associated costs should an incorrect payment be made—two points specifically noted in the cross-agency priorities of the recently-released President’s Management Agenda—are vital to helping solve the challenges.

However, these improvements represent a bare-minimum approach that doesn’t go nearly far enough in addressing the totality of real-world issues faced by the industry today.

There are a number of things we as government and commercial contractors can do to help greatly reduce the amount of fraud, waste and abuse that exist in the marketplace beyond simply improving prepay and post-pay solutions.

Doing so, though, requires us to take a much more holistic approach to addressing the problems at hand.

Using both traditional and non-traditional methods, here is one person’s five-tier approach to developing and implementing an end-to-end fraud, waste and abuse solution:

  • Prepay: The first part of the recovery audit service process includes post-adjudication by the payer (to ensure the amount that’s scheduled to be paid is correct) and a high-dollar review which mandates that prepay claims are made—in sequence—from the highest dollar amount to the lowest to help protect the payers’ liability. This step also includes semi-complex audits to allow for an improper payment review and expedite the recovery process.
  • Post-pay: The second recovery audit service process is very much the same as the first with one major difference: it takes into account that the provider has already gotten paid. The payer is informed that they’ve overpaid the claim by a specific amount and the provider is sent a findings letter to let them know the amount of the improper payment.
  • Industry Solutions: While this tier also utilizes recovery audits and payments, the primary driving force behind industry solutions are technology. For instance, my company uses its own proprietary data-driven technology— CGI ProperPay® —to predict, identify, manage and recover medical and pharmacy claims that have been improperly paid. The Internet of Things can also be utilized here. Best of all, these industry solutions can be used in conjunction with a payers’ audit department to supplement their efforts.
  • Protection: For an organization to have full 360-degree protection, its social media presence must be monitored. The organization’s online presence needs to be protected from targeted phishing attacks, credential compromise, data exfiltration, brand hijacking, executive and location threats and more. Diverse data sources and artificial intelligence-based analysis can also be used here to provide the organization with real-time identification of potential fraud and impersonations and institute automatic takedown procedures off offending posts, messages and accounts to help limit exposure.
  • Reimbursement Services: This helps protect an organization’s future state. Data gathered throughout the recovery audit process is used to recommend changes to the payer. These new wrinkles—whether they be in policy, direction or billing—are intended to reduce the number of improperly submitted claims. This helps the organization generate as much recovery dollars as possible through improper payment audits while simultaneously re-emphasizing or implementing policy changes to help organizations avoid making the same mistakes down the road.

It’s important to note that while these tiers are related, they do not need to be performed in succession. While prepay (naturally) has to come before post-pay, industry solutions, protection and reimbursement services are separate and can all happen simultaneously.

The benefits to this one-stop shop approach are many. For instance, using this framework, my company has recovered roughly $2.8 billion in improper medical and pharmacy payments in the last eight years alone.

We’ve done this within the backdrop of using industry standard best practices (PMP, Lean Six Sigma, etc.) and we’re currently working with Microsoft to add predictive analytics and best practices via the secure Azure Cloud to the mix. Additionally, utilizing this holistic framework has seen savings rates in excess of 40 percent, far above the typical 20 percent to 25 percent. The quality of our findings has also led to an appeal uphold rate of greater 93 percent. The bottom line: payers can count on this holistic approach.

While it’s unlikely that we’ll ever be able to fully eradicate these issues, there are a multitude of things we can do now to help stem growing tide of fraud, waste and abuse. Best of all, these solutions not only translate into dollars and cents, but also peace of mind for payers.

About the Author

David Ott is the director in the consulting services practice at CGI Federal Inc.

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