Combating Fraud, Waste and Abuse

Transcription

1 Combating Fraud, Waste and Abuse SPECIAL INVESTIGATIONS UNIT OUTSOURCING

2 Fraud investigation is as complex as piecing together an intricate puzzle. Re-imagine Your Fraud, Waste and Abuse Management Strategy Expand anti-fraud efforts with expert SIU Outsourcing solutions Fraud and other improper payments drive up healthcare costs for everyone. The impact the estimated tens of billions of dollars lost to fraud, waste and abuse (FWA) 1 on America s healthcare system isn t new news anymore. What is new is increasing pressure from regulatory agencies and how your plan will fight fraud in the age of healthcare reform. In order to solve this challenge, you need access to the right resources. Most SIUs find this to be difficult because investigations require specialized skillsets. Outsourcing all or part of your investigative work could be an answer. Advantage: Outsourcing Outsourcing SIU is becoming an attractive way to fight FWA for several reasons: Manage costs SIU staff with high-value skills and continuous training needs are costly to maintain. Outsourcing allows a health plan to augment existing staff or fully offload those responsibilities, reducing costs and helping your plan meet medical loss ratio requirements. Leverage unique investigative skills Access to a variety of highly specialized investigative skills such as coding and strong data analysis skills, can be difficult to recruit and maintain. Access to the newest technology An outsourced SIU from a leading FWA partner could offer the best of both worlds: expert staff using the latest in fraud detection and case management technology. A Documented, Systematic Approach Producing Results Employing a consultative approach, the STARSServices team works with your existing staff to design and implement a customized solution. Our comprehensive approach improves your fraud detection ability through detection and investigation outsourcing support, customized consulting and complete training programs as we: Identify your unique goals and objectives Analyze existing data and suspect claims Recommend an approach maximizing detection abilities and complementing your company s current resources By implementing the right tools and resources for continued fraud control, you can realize: Improved opportunities for fraud recovery Major cost savings Provider awareness and education Return on Investment (ROI) ABOUT GENERAL DYNAMICS IT General Dynamics IT has a thorough understanding of healthcare billing, claims processing and fraud, waste and abuse. Our industry-leading SIU team is backed by an organization with more than 30 years of experience aggregating and analyzing data. You can count on keen insights, rigorous analysis, smooth implementation and superior service. FAST FACTS More than 50 large-scale data warehousing deployments More than 2.5 billion claims stored and analyzed annually More than 300 million covered lives analyzed annually 60 of the top 200 health plans use our healthcare informatics solutions 1

3 Access to the newest technology An outsourced Special Investigations Unit from a leading FWA partner could offer the best of both worlds: expert staff using the latest in fraud detection and case management technology Manage costs associated with outfitting, staffing and maintaining an SIU Comply with CMS and state-mandated, anti-fraud program requirements Produce improvements to overall financial performance and influence quality of care Realize Return on Investment (ROI) Put a Uniquely Qualified Staff to Work for Your Business Your outsourced program s success is dependent on choosing the right business partner. Our highly qualified STARSServices SIU staff measures up on all the key attributes: Depth of healthcare and healthcare fraud knowledge Understanding of regulatory and compliance requirements Reputation and customer service approach Ability to track and quantify results Quality of investigative output Customized, Comprehensive Outsourcing Options Selecting from a menu of anti-fraud outsourcing options allows you to achieve an optimum balance for your business model. Outsource components of your existing FWA management strategy, or fully delegate SIU responsibilities to the qualified STARSServices team. Or, engage our SIU leadership experts to help you prepare for an SIU compliance audit, create policies and procedures or establish workflow processes based on field-tested best practices. Available services include: Lead generation SIU support Clinical review services Appeals support Services verification Fully staffed SIU Consulting Facility audits Policies and procedures development and/or review Fraud plan assessment Qualifications Real-world experience establishing and managing commercial SIUs Premier FWA credentialing, including: Accredited Healthcare Fraud Investigators (AHFI) Certified Fraud Examiners (CFE) Certified Fraud Specialists (CFS) Certified Professional Coders (CPC) Certified Professional Medical Auditors (CPMA) Registered Nurses (RN) Juris Doctorates (JD) Certified Pharmacy Technicians (CPT) Registered Health Information Administrators (RHIA) Licensed Healthcare Risk Managers (LHRM) Qualified trainers at the industry s premier training venues: National Health Care Anti-Fraud Association State Fraud Bureaus American Academy of Professional Coders State and Federal Law Enforcement Agencies America s Health Insurance Plans Experience investigating and documenting cases for prosecution or administrative recovery, working with state and federal law enforcement STARSServices Staff Profile

4 Put together the services you need, creating your ideal FWA outsourcing model. Lead Generation Utilizing our industry-leading software solutions, your outsourced investigators generate provider and member summaries, including overall scoring against known fraud schemes. Analysis at the claim-line level develops a picture of providers practices and billing patterns or members with suspect utilization activity. Using an investigative template, these aberrant practices are illustrated and recommendations for remediation are supplied for each finding. SIU Support Expand your SIU staff easily, efficiently and on demand with our SIU support services. Outsourced investigators can support your existing SIU, allowing internal staff to focus on functions best managed in-house. Outsourced investigators will triage your hotline tips and leads from other sources, determining which allegations of FWA warrant further investigation. They conduct an initial investigative analysis, including internet research, or derive a statistical sample, perform a medical record review and pursue overpayments. Our skilled, credentialed management staff can also create investigative workflows to standardize and document processes within your SIU. Fully Staffed Special Investigations Unit If your FWA management strategy calls for a more aggressive outsourcing model, our experts will collaborate to create a fully staffed SIU team. This team will act as your in-house SIU executing the full range of FWA management responsibilities, including: Assessing leads/tips from internal or external sources Mining claims data and generating leads Conducting full scope investigations Documenting cases Making appropriate referrals for administrative or regulatory/law enforcement resolution Negotiating settlements on your behalf Pre-payment monitoring of subjects with a history of aberrant billing patterns Pharmacy Lock-In Support Many Medicaid managed care plans have pharmacy lock-in programs designed to mitigate abuse by restricting beneficiaries to the use of specific pharmacies for their prescriptions. Our SIU supports these programs by providing a clinical assessment of all available and pertinent claims data, such as medical, pharmacy and facility. These claims might reveal potential drug-seeking behavior by beneficiaries. Plans can help keep members safe as well as safeguard against inappropriate losses due to potentially abusive behavior. FRAUD, WASTE AND ABUSE TRAINING PROGRAMS: Fraud schemes Durable Medical Equipment (DME) Mental Health Experimental/ Investigational Procedures Dental Pharmacy Site Audits Investigation and case documentation skills Management and leadership Compliance training

5 We can help you prepare for an SIU compliance audit, refine policies and procedures, define staff development programs, maintain in-house staff investigative skills through training programs and implement nationally recognized best practices. Appeals Support Our clinical team bolsters your internal SIU or appeals team, especially as it relates to those claims where an FWA investigation was involved. In many organizations, FWA appeals are sometimes lost in the realm of other types of appeals and might be overturned despite significant evidence a decision should be upheld. We help your organization manage this process through an integrated and thorough approach efficiently providing a clinical perspective to potentially fraudulent, abusive or wasteful claims. This way you have the clinical and investigative expertise needed to manage your SIU appeals demands. Claims Verification Services In states with Medicaid Managed Care Organizations, the state requires the health plan verify services directly with the recipient rather than the provider. These verification initiatives might overlap or prompt FWA investigations based on the findings of the recipient outreach. Our team of expert investigators and analysts will compile the service verification results in an actionable manner so your program complies with state regulations and identifies aberrant providers and submit claims for your beneficiaries. Customized Consulting Services The STARSServices team provides customized consulting services, independent of software, providing value throughout your anti-fraud program. Whether you re creating an SIU for the first time or already have one in place, we can help you prepare for an SIU compliance audit, refine policies and procedures, define staff development programs, maintain in-house staff investigative skills through training programs and implement nationally recognized best practices. Audit Preparation State and federal insurance regulators are increasingly auditing anti-fraud programs as a result of major legislation including provisions for FWA compliance. As federal and state agencies exercise their right to audit FWA programs, you need to be prepared and proactive. Utilize STARSServices to review your SIU s policies and procedures and provide written reports summarizing findings and recommendations. Our experienced staff can create work plans and risk assessments and help you understand how to: Approach documentation preparation Employ tools and resources to ensure your team can demonstrate proactive detection of potential fraud, waste and abuse Institute safeguards to prevent deficiencies

6 Policies and Procedures Documentation To ensure your plan is adhering to new guidelines set by regulatory agencies, including state departments of insurance and fraud bureaus, the STARSServices team can review your existing policies and procedures and make recommendations to improve compliance. Working with your leadership team, our experts create remediation plans addressing requirements specific to each state in which your plan operates. Staff Goals and Development The effectiveness of your in-house SIU depends on maintaining a well-trained and motivated staff. By tapping into our team of experienced SIU managers, you can create objective, measureable goals that help staff improve delivering overall value to your organization. Executive Advisory Services - Best Practices and Management Review Our SIU outsourcing team is led by accomplished SIU management professionals. This well-qualified, well-networked team has demonstrated results and built successful investigative units. Consult them and tap into best practices used by peers in the industry to improve your SIU s efficiency. When consulted for formal analysis, our team provides feedback on areas for improvement including intake and case assessment processes, implementation of new processes and assistance with succession planning. Complete Training Programs Our anti-fraud training programs include a curriculum of basic to advanced courses providing you in-depth understanding of healthcare fraud, detection and investigation. Courses are conducted by experienced SIU investigators and each course can be taught on site at a preferred location.

7 Find Out More We offer a suite of solutions leveraging the power of your healthcare information to help control costs and protect you against healthcare fraud, waste and abuse. Learn more about STARSSolutions and STARSServices. Online: info@gdit.com Phone: x8010

8 3211 Jermantown Road Fairfax, Virginia /3/14 General Dynamics Information Technology is an Equal Opportunity/Affirmative Action Employer Minorities/Females/Protected Veterans/Disabled General Dynamics Information Technology. All Rights Reserved.