Spotify’s 2021 Wrapped told us that this past year was anything but normal and we agree. Did you watch your soundtrack? So did we and we are proud to say we understood the assignment in both music and at work.  While working with payers and providers to drive down the cost of healthcare and increase compliance, we have seen some trends in the Fraud Waste Abuse and compliance space this past year. 

Customer Service is Dead.

It isn’t just at airports or restaurants that people aren’t showing up for work.  We see it in healthcare services as well.  With the M&A occurring in the vendor space, we have seen customer service decrease at alarming rates.  We have had 5 clients join us this year specifically for our turnaround time and overall responsiveness.  We answer the phone or call them back and always respond to emails.  It is hard and sad to see this be an issue for customers who are paying a vendor.  We had one client in particular who specifically told us that they just wanted to hear back from us when they called.  Apparently, returning a call is more of a challenge than it appeared.

No Vax No Job

We continue to hear from our clients on a regular basis that they need people who are vaccinated on their projects. If You Lose Your Job, You May Not Get Unemployment Benefits.

Customer is Always Right – Surprise!

The consumer focus in healthcare is continuing.  Consumer expectations continue to drive care and delivery models.  Unexpected Medical Bills are one of the hottest topics discussed across the healthcare continuum and the No Surprises Act is being discussed everywhere.  Here is an article that outlines one state’s governor who celebrates increased consumer protections.

Technology in Healthcare

Digital therapeutics and telemedicine treating chronic conditions are just two of the emerging technologies that we are looking forward to watching. We have seen providers and patients move ahead with finding ways to improve care.  2021 was a year for hot deals with many venture funds getting involved.  Startups are leading the way to innovations and there is so much with data analytics and AI. Telemedicine is here to stay, and we are sure that there will be an increase in access as technologies evolve, and they become increasingly easier to navigate (particularly for the older, and less technologically savvy population).

Price Transparency

Price transparency is happening and that it will rock the world of healthcare.  Do you believe the forthcoming transparency wave will provide unprecedented insight into fraud, waste, abuse, and overpricing? Check out The Dawn of Self-Insured Transparency: Shining Light onto Fraud, Waste, Abuse, and Overpricing, the first of a series of essays that our colleague and friend Tia Goss Sawhney wrote.

Analytics: In Our World

We have seen our fraud waste and abuse universe get more aggressive with overpayment analysis based on statistical sampling.  Providers who are audited and have an overpayment resulting from an SVRS should have that methodology reviewed as possible challenges to the methodology.

Aggressive US Attorney prosecutions heavily relying on “intended” loss calculations that are based on the billed amount, and not the paid amount.  This can have a tremendous effect on the potential prison time a provider may get, as billed amounts are substantially higher than paid amounts 

COVID 19 labs are going to be under heavy scrutiny as it relates to claims for testing, COIVD 19 add on tests and the documentation maintained by labs to support claims for insurers and HRSA (under the CARES Act)

By Jeanmarie Loria