As I look out the window, the sky looks grey and ominous that a storm is on the way, but it is still almost 50 degrees outside. All things point to spring, but the sky hints of yet another storm before it too goes out like a lamb and hopefully not out like a lion. This is NOT typical of a winter here in the upper Midwest and it reminds me that sometimes the weather can be much like the lifecycle of Healthcare Fraud Waste and Abuse Investigations, a lion or a lamb.

As an Investigator takes on a new investigation, some of the investigations look much like a quiet lamb and transition to a roaring lion very quickly. A seemingly straightforward unlicensed personal care assistant (PCA) allegation should be a relatively simple process. Are we as Investigators really looking at all aspects of opportunity to enhance recovery by doing a proper due diligence each time?  An Investigator can use creative thinking to make the most out of each opportunity,  regardless of whether your investigation is a lion or a lamb. Investigators should consider all leads available including data mining, provider/member interviews, documentation review and related regulations, policies and coding requirements. Utilizing all resources (instead of dismissing the investigation based on initial review) enhances criminal referrals and recoveries yielding an environment of doing more with less.

Ensure each case is what you want it to be, a lion or a lamb by doing your due diligence to make the most of each opportunity. Don’t spend time on what will not yield positive results. 

How I determine if an investigation is a lion, or a lamb is based both on creativity and mindset. Never make your entire decision on the initial review of an investigation. Always check all aspects of the lead and access all opportunities available. No matter your experience or background, this is a learning process – don’t let your ego eclipse your judgement. Great Investigators can develop a skewed vision based on failure to learn and evolve. I started in this business in 1997 and every job, contract, jurisdiction (state, local and federal), and task related to the same thing – “do more with less, be creative and lead by example.” Today, everyone is faced with learning to “do more with less,” both personally and professionally. Learn to be adaptable.

A seemingly simple unlicensed PCA case evolved to being accepted criminally using all the resources identified below and looking beyond just the value of recovery dollars. Taking a day for interviews can solidify a referral for a criminal case or enhances recovery dollars. Always stay in control of the investigation from the beginning. Doing a simple inpatient overlap report to determine if there are additional prohibited services is an easy way to enhance an investigation. Providers, patients, and attorneys inherently respond better to Investigators demonstrating control and clear communication throughout the process.  Here are some key elements to consider:

  1. Investigations are not worth the resources and don’t demonstrate the most responsible use of resources to ensure return on investment (ROI).
  1. Understand the allegation but look beyond it by reviewing all aspects available to maximize opportunities.
  1. Know your payor, policies, regulations, and resources.
  1. Leverage data analytics and data mining – Use it to tell the story.  Having a data analytic tool that generates leads that are simply not able to be worked because of the “do more with less” mentality is waste of time, effort, and most importantly, ROI resources.  What is the value in generating leads that are not able to be worked?
  1. Review all resources available to show opportunities to demonstrate prior knowledge and intent. Always check the internet. Information is at our fingertips – use it.
  1. Leverage your CPC Auditors/Nurse CPC staff. Remember a CPC Auditor and a CPC Coder provide a very different outlook.
  1. Do interview members/providers.
  1. Document education and corrective action plans. They are instrumental in behavior change and essential should the behavior continue. 
  1. Keep the progression of a case moving forward; never let your case sit. The older the case, the more difficult it is to make a positive referral or recovery. Always listen to your instincts.
  1. Failure to perform due diligence sets an environment and image of opportunity for FWA in your jurisdiction. Someone is always looking to find a place to start another scheme. Be a leader in quick identification and reactions to these trends and patterns.
  1. Always do more with less. Challenge yourself and always do better. 
  1. Always know each investigation you perform defines you and your contribution to the payor you represent and the small world of FWA. Your connections assist in creating your own professional network, so make a good impression. Ensure your actions reflect the image you desire.
  1. Make sure each case is what you want it to be, a lion or a lamb, by doing your due diligence to make the most of each opportunity. Always prepare each investigation as if it will sit in front of a judge. 
  1. Don’t spend time on what will not yield positive results. Do make sure your theory is credible. Don’t speculate; verify your hypothesis. If it doesn’t hold water if verified and you base your decisions on this, it reflects back on you. Make it count. Learn from mistakes.
  1. Do go onsite when needed. Verify.

What image legacy do you want to leave behind? A lion or a lamb in FWA. 

By Carey Mead Lead Investigator Advize Health LLC