In SIUs, just like in any other organization, eternal questions always come up:
- When do I get my raise?
- What time is lunch?
- Where’s the “Any” key?
But the biggest question is – Who has the most important job?
Is it the Data Analyst whose work identifies the suspect providers? Is it the Medical Review Nurse or Coder who makes the claim determinations that are the foundation of the case? Or is it the Investigator who gathers the evidence? Perhaps it’s the managers, team leads, or administrative staff who keep the whole operation running…
The answer, simply, is – The Most Important Job is YOURS.
Every case is a puzzle, and the work done by each person on the team contributes pieces to that puzzle until it is complete, and everyone can see the whole picture.
So, what does that mean?
It means that to be truly successful, there needs to be coordination, collaboration, communication, and integration for an SIU to be successful.
- A data project created in a vacuum without input from the clinical team or insights provided by the investigative team will be missing essential elements.
- A medical review that is done without knowing the facts of the case for which the review is being conducted may miss key aspects because they didn’t know to look for them.
- An investigator independently looking at data may misinterpret what the numbers and trends are pointing at.
- Conducting an interview with a provider without collaborating with the clinical staff may result in the investigator being unprepared to counter the clinical word salad put forward as a defense.
There is no completing the puzzle without everyone’s contributions, and that is why everyone should consider their job to be the most important. Any successes are the results of the team, and the root cause of most failures is the siloing of the team into separate fiefdoms.
The efforts of every team member should last throughout the life of the case.
- Data analysts should continue to provide insight to the team as new facts emerge.
- Clinical staff should offer clinical insight into the data project (to make sure the findings are not false positives). This insight should continue to be given as interviews with beneficiaries/members are conducted – connecting medical review findings with the patients’ own recollections of the services.
- The investigator should provide continual updates and ask for guidance and advice as more pieces of the puzzle are found. Without that, the puzzle will always be incomplete.
Happy hunting – and remember, it is always safer to hunt in packs.