All Articles Healthcare End-to-End Program Integrity: Eliminating Gaps and Meeting Business Objectives


End-to-End Program Integrity: Eliminating Gaps and Meeting Business Objectives

The most effective payer programs for fighting FWA are tailored to each organization and integrate end-to-end capabilities.

5 min read



Jessica Gay, AHFI, CFE, CPC, serves as service delivery manager with General Dynamics Health Solutions, where she is responsible for end-to-end customer support for a variety of healthcare payers. Erin Picton, AHFI, serves as manager of investigations for General Dynamics Health Solutions, overseeing the team’s Special Investigations Unit and its customer support and programs. As program integrity (PI) professionals, Ms. Gay and Ms. Picton help health payers achieve their anti-fraud, waste and abuse objectives by designing, developing and deploying unique program integrity solutions to meet each plan’s needs. They spoke with SmartBrief about the key elements of a complete, end-to-end program integrity approach and will discuss the topic more fully at the 2016 National Healthcare Anti-Fraud Association conference on Wednesday, Nov. 16, at 11 a.m. at the Hyatt Regency in Atlanta.

What are the key elements of an effective PI program?

Jessica Gay:  One of the most important considerations for health plans in creating a well-rounded program integrity initiative is understanding their organization’s intricacies, such as the lines of business covered, organizational structure and organizational support for fraud, waste and abuse (FWA) efforts. Taking this information into account, program integrity efforts should be tailored to the plan’s specific needs. In addition, plans should utilize all possible tools and interventions available to them. These may include anti-fraud software to conduct pre- and post-payment reviews of aberrant providers, generate leads, support queries and manage investigations. Software should be routinely updated, regularly include FWA identifiers, and offer usability and interoperability across all investigative phases, such as the ability for pre-pay modules to continuously reflect insights gained through post-pay review. When possible, plans should leverage internal and external investigative resources, such as third-party solution providers, law enforcement and/or state partnerships. In terms of prevention, pharmacy lock-in programs can reduce fraud and drug abuse risks and provide cost savings by restricting members to specific pharmacies or prescribers, while also increasing the quality of care.  

Have you seen examples where payers focus strongly on one area of PI to the exclusion of others, and do you have recommendations here?

Jessica Gay: Yes. Many health plans tend to heavily focus on pre-payment review or post-payment review programs, but not both. Focusing on post-payment review programs appeals to organizations because it can drive returns on PI investment. While post-payment review is critical, these reviews take a long time to generate results and focus on improper payments that have already occurred; pre-payment review can prevent inappropriate payments from happening in the first place. Conversely, some health plans focus primarily on broad pre-payment review programs (which may include gaps) without considering a post-payment review component that identifies the specific areas that may warrant investigative focus. Better overall results and ROI can be realized by confirming the value of pre-payment review through post-payment review findings. In addition to integration of pre- and post-payment programs, some plans are not taking advantage of other important investigative components, such as service verification and pharmacy lock-in programs, which can help mitigate risks and capture savings and recoveries.

What oversights or gaps should payers avoid when implementing a pre-payment claims review program?

Erin Picton: Far too often, we see plans initiate a broader, more global model of claims review rather than a focused approach. By implementing a pre-payment claims review process that doesn’t consider factors or FWA indicators – such as post-payment review identifiers, proactive data analytics, prior member complaints, exclusions and disciplinary actions – plans run the risk of manually processing more claims than they can effectively manage. This model strains internal resources by increasing the administrative support needed for the entire pre-payment process. Additionally, this model can unnecessarily strain providers who submit appropriately billed claims that are flagged but ultimately overturned on appeal. Creating a targeted list of providers, members and claims for pre-payment review, based on initial findings from data analysis and investigative resources, allows plans to focus on true potential problem areas with greater success and ROI.

How can PI professionals ensure executive/management staff understand the importance of focusing on program integrity?

Erin Picton: PI professionals may find it challenging to convince management of the importance of program integrity. Many health plan department managers can be sensitive to anti-fraud efforts, which can feel counterproductive to the success of their department due to costs and resource demands on provider networks. Because executives must find the right balance between business needs and patient care, an effective program integrity plan must foster collaboration throughout the organization and support care and quality initiatives while also serving the plan’s financial drivers and addressing FWA.

What program components are essential to deterrence, detection and prevention of FWA?

Jessica Gay: The essential components of a successful FWA program include employing the appropriate personnel and equipping them with the tools necessary for success. Most successful program integrity units have staff with diverse experience and expertise, including individuals with prior government/regulatory and/or investigative experience, clinicians, coders and data analysts. If a payer’s staff lacks these professionals, they should consider working with a solution provider that can augment the team in specific areas of need. Even the most capable staff needs software tools and technology to meet today’s range of anti-fraud challenges – ideally, software that includes pre- and post-payment FWA detection abilities, case management, ad-hoc query capabilities, and expert support and enhancements.

If there were a single initiative that could enhance the industry’s fight against fraud, what would it be?

Erin Picton: The movement to leverage pooled data for fraud scheme and trend detection stands to significantly improve the effectiveness of program integrity efforts around the world. The volume of analysis and insights that can be derived from analyzing provider behavior across multiple states, lines of business and benefit categories is invaluable. The more plans and professionals that participate in sharing and utilizing data, the greater the benefit to the entire industry.