FierceHealthPayer: Anti-Fraud: What are some early indicators SIUs can watch for signaling that reports of potential fraud, waste and abuse may become significant or urgent cases?
Mike Little: Assessing allegations early is a challenge, but taking some specific and general steps can help SIUs determine if a case may become a priority. The first specific step is assessing the allegation. What's involved, and what's the scope of the issue? Could it be part of a larger problem or national scheme with the potential for media attention?
Also check if patient safety is at risk. Financial harm at the expense of patients is an area that becomes urgent very quickly. And different case steps are necessary if patient safety issues are involved as opposed to financial issues alone. Are there signs that unlicensed individuals are at work? This can raise questions about your company's credentialing and due diligence processes that affect patient safety.
And lastly, determine if employees from your organization may be implicated. That may cause reputational harm and indicate internal control weaknesses.
But insurers and the federal government can no longer wait for complaints to arrive because often by then there's been significant loss. So SIUs should also take general steps to spot trends and risks. These steps involve knowledge.
First, plug into a healthcare fraud task force. These exist nationwide and include other SIUs and federal and state law enforcers and regulators. These groups are the wave of the future in terms of public and private partnerships. There's a great deal of information shared about what's happening at other companies or in other segments of the community.
Second, participate in larger anti-fraud organizations to discuss trends and best practices and interact with other payers in a learning environment. Third, use data analytics. It's important to have the ability to slice and dice information, to use clustering and link analysis to understand potentially significant cases and trends.