Take this interactive self-assessment to evaluate your current SIU successes and determine your health plan’s need for advanced technology to level up your fraud, waste and abuse mitigation efforts. 

More advanced technology solutions for healthcare fraud detection, analysis and management are now readily available on the market. But, if you’re used to traditional rules-based tools siloed from other cost containment functions, the mindset shift required to think a little differently about how best to augment the SIU’s expertise can be daunting. How can your health plan properly prepare to take advantage of an advanced FWA technology solution? Take the interactive self-assessment to find out. 

Self-Assessment: Evaluate Your Readiness for Advanced FWA Technology 

The first step when considering upgrading enterprise technology solutions – for any area of your health plan – is thoughtfully considering your current state. While there are no wrong answers, this self-assessment will help you level set on some key areas of evaluation and decision making to better prepare you for successfully adopting a modern FWA solution.

Your Results: How Did You Score? 

Now that this assessment has provided a framework to evaluate your current efforts to mitigate FWA, your scored answers can help you determine a suggested path to successfully adopting advanced technology for fraud detection, analysis and management. 

5-13 points: Time to access outside expertise 

At this level, your SIU may not have access to sufficient personnel and data science resources to make significant gains in your FWA mitigation efforts. The time spent running down false positives and manually compiling reports to satisfy regulatory compliance requirements only exacerbates the issue by further constraining over-taxed clinical and investigative experts. If you’re like many teams being asked to do more with less, how can you get ahead? Next steps: 

  1. At this level – especially if you struggle to maximize your value from current tools – the very idea of adopting advanced technology can seem an insurmountable obstacle. You’re not alone in this feeling, and it’s possible to catch up.
  2. An achievable goal is working on tackling overpayments in whatever form they come – namely, wasteful billing practices. Working with the audit function at your health plan and shoring up payer-provider relationships are excellent foundational best practices that can make your FWA function more effective. 
  3. While advanced technology, clinical audits and investigative capabilities are the three pillars of preventing and mitigating FWA, it’s okay if your SIU isn’t well-resourced in all of those areas. Outside expertise can help you shore up any gaps until you are ready to internalize additional functions. 

14-17 points: Integrating FWA and Payment Integrity yields dividends 

You’ve been able to make a great deal of progress on your own up to this point, and that is to be commended. But your current siloed tools that keep your SIU team disconnected from other areas of cost containment may be holding you back from real gains. Next steps: 

  1. Are your current tools for fraud detection, analysis and management as advanced as you think? Most are based on decades-old technology. These three tell-tale signs can help you investigate the differences. 
  2. Your FWA efforts may be stymied by a lack of key information if you’re not well aligned as an integrated, total payment integrity function. Watch this 10-minute presentation any time for a look at the consequences of these data silos and the five benefits of eliminating them. 
  3. Start thinking about how advanced technology like deep learning models can help you overcome perennial challenges like false positives and manual processes. This on-demand webinar is a great educational resource. 

18-23 points: Ready to take your FWA efforts to the next level 

Relying solely on the rules-based tool your SIU has worked with for years is no longer the sophisticated strategy your innovative organization has historically found success with. And advanced data science teams that are still relying on predictive analytics understand that applications of artificial intelligence have progressed to an ideal and achievable solution for mitigating healthcare fraud and abuse. Next steps:

  1. When you go looking for an advanced technology solution for FWA, it pays to understand that all A.I. isn’t created equal. Here are three questions to ask to determine if the solution you’re investigating is the real deal. 
  2. Connecting disparate data sources – geographic, weather, financial, audit data and more – that provide context to aberrances enables your SIU to work smarter. Here’s how exactly deep learning models help address the complexity of healthcare data that foils simpler tools – while overcoming the interpretability hurdles presented by A.I. results. 
  3. While you don’t have to give up your reliable rules-based tool to take on an integrated fraud detection platform like Pareo, which is powered by A.I. based on deep learning models, ferreting out potential fraud and abuse without rules is a mindset change. This article helps explain the difference in the approaches, including how, by working with a modern FWA solution, your internal experts continue to provide a key competitive advantage for your health plan.

Bottom Line: Setting Expectations is the Key to Success 

No matter how sophisticated your current FWA operations are, you can successfully adopt advanced technology that helps you maximize avoidance and recoveries at the most optimized cost. Along with the stage-specific recommendations we offer above, here are three additional pieces of advice: 

  1. Start by setting realistic goals based on what is it that you want to accomplish. How do you want to use this technology in order to address the core challenges you’re facing? 
  2. Determine if your staff is organized appropriately. If your goal is to increase your case level or increase your savings, does that mean that you’re going to need additional staff? How would you organize (e.g., by line of business or product line)? 
  3. Prepare your SIU for the change. How will advanced technology affect your workloads in your day-to-day operations, and how do you make the most of your role? 

 Do you need help preparing for and navigating this change? Don’t hesitate to turn to us for fear that it’s too early to engage a partner in this processYour SIU can benefit greatly from advanced FWA technology that features true A.I. powered by deep learning models and seamlessly connects fraud detection, analysis and management. Those benefits are compounded greatly when they’re natively integrated on a platform like Pareo that also engages with overall payment integrity activity. This integration offers unparalleled visibility into the progress your team is making toward their goals and helps prove their sizable impact on cost containment at the health plan as a whole.

 

NOW'S THE TIME FOR TOTAL PAYMENT INTEGRITY

Talk to ClarisHealth about how Pareo®, a total payment integrity platform, is driving innovation at health plans.