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Special Investigations Units: Best Practices and Emerging Considerations

5 min read


Jala Attia

This post is sponsored by General Dynamics Health Solutions.

Jala Attia, AHFI, CFE, serves as Senior Program Director of Special Investigations Unit Services and Business Process Outsourcing for General Dynamics Health Solutions, overseeing the group’s Program Integrity Services solutions in support of health payers. She has dedicated the past 15 years of her career to finding, investigating and deterring fraud, waste and abuse, and prior to joining General Dynamics Health Solutions was an SIU director of a national health plan, overseeing commercial and government investigations across the country. She previously served on the Board of Directors for the National Healthcare Anti-Fraud Association (NHCAA) for several years.

Here she answers a few questions on topics her team addressed in their SIU Best Practices panel at NHCAA’s Annual Training Conference.

Question: Where are some often over-looked areas where a Special Investigations Unit (SIU) can improve fraud, waste and abuse (FWA) investigations?

Jala Attia: One overlooked area is taking full advantage of no-cost information when investigating an allegation. As investigators, we generally favor a few sources of information and rely primarily on those. But there are a variety of other sources that can help in FWA investigations. In addition to typically available public records data, the OIG and State Exclusion lists, PACER (Public Access to Court Records) or even can prove powerful. It’s not enough to simply analyze claims data – you want to create a full picture of behavior and the more information you can compile, the better informed you will be. For example, allows you to review and analyze tax returns for non-profit organizations and to review reported income.

Another thing to consider is that most investigations deal primarily with providers and the information they provide, underestimating the value of the member. Don’t forget the member’s role in a claim. Sometimes, they can provide the most pertinent information to your case or could be an active participant in the scheme.

Q: What are some best practices for medical review and coding?

JA: When reviewing medical records, I recommend you be sure to review the records in the manner the sample was derived. For example, don’t focus your review by claim line if you sampled by member, which could cause you to miss the bigger picture and to allow something that should have been denied, or vice versa. An analogy would be denying a glucose monitor but allowing test strips simply because of the way the data was organized during the review.

Another crucial practice is to maintain a solid and consistent quality oversight process. This can help avoid the embarrassment – as well as financial costs – of a provider or provider’s attorney pointing out an error. One error can undermine the quality of your medical review, and your entire investigation is likely to be scrutinized and questioned more closely.

Q: What are some new trends that health plans might expect to see?

JA: ICD-10 is a hot topic right now, and providers may be expecting health plans to afford the same flexibility being offered by the Centers for Medicare & Medicaid Services (CMS), with a one-year period of claims payment review leniency for ICD-10 codes derived from the appropriate family of codes. However, CMS has clarified that each health plan will individually determine whether to offer the same period of leniency. We recommend you monitor providers that you have existing cases on, in order to discern if their billing patterns change. If you have concerns, quickly educate providers on the appropriateness of their billing and continue to monitor them. If you can catch the behavior early or keep it from happening altogether by educating, it’s a win-win.

Also, in August, a Local Coverage Determination (LCD) was issued authorizing payments for a prognostic test to assess the aggressiveness of prostate cancer. We expect more tests of prognostic and genetic nature to be approved for payment. As technologies improve and more lab companies are established, we believe health plans should also expect to see an increase in costs associated with genetic testing.

Q: How can a plan ensure its SIU and Program Integrity vendors are operating optimally to meet challenges?

JA: A vendor relationship should represent a partnership and a commitment to a payer’s success. In addition to an effective technology solution, payers should expect many things from their vendors, including but not limited to:

  • Providing SIU support, having effective policies and procedures in place related to sampling methodologies, investigations, medical reviews, interviews, audits and other investigative components;
  • Setting clear standards for turnaround time with respect to investigations or medical reviews, and providing verification of adherence to these standards;
  • Providing regular updates on progress and key performance indicators that your organization has identified;
  • Providing best-practice insights on opportunities to improve your SIU (e.g., an assessment of how efficiently your investigative team is using FWA tools);
  • Identifying risks specific to your organization that may be causing unnecessary spending;
  • Regularly requesting performance feedback and making associated improvements; and
  • Avoiding complacency that could develop as you work together over time (e.g., your vendor failing to provide you with required reports in a timely manner or consistently missing deadlines).

Q: What is the single most important thing an FWA vendor can do for their clients?

JA: Vendors should absolutely think like fraudsters, be imaginative and search for ways that providers could possibly target their clients. If you partner with a vendor who is actively engaged in detecting and deterring fraud, waste and abuse for you, that’s a relationship worth keeping!