It’s no wonder Advize celebrates Pi Day. Pi (pie) is magical. In one form it is a mathematical constant that is used in complex mathematical formulas (what would be the purpose of any Texas Instruments’ calculators without Pi?). As a food, it can be a main course (savory pies, chicken pot pies, pizza pies) or a dessert (what is Thanksgiving without pumpkin pie) and as a business tool, where would any of us be without the illustrative power of the pie chart. Even further, pie has become part of our culture. Expressions like “Baseball and apple pie” and “getting your piece of the pie”, are part of our lexicon and events like pie eating contests and County Fair bake-offs are popular culture standards.

But Pi(e) is important to Advize because of its importance to health care fraud program integrity. (Yes, this is the part where I strain metaphors to the breaking point).

Pi is symbolic of the importance of math and statistics in everyday life. This is no less true in health care fraud. Data is the life blood of health care fraud investigations. Looking at the numbers, understanding them, putting them in context and finding their patterns is what generates the vast majority of our successful cases. The use of analytical tools like SAS or Python, AI, machine learning tools, and link analysis software are all helpful. With them, you can create models that identify large scale schemes or program vulnerabilities (especially those where medical review is not needed) which will elevate your ROI. To be truly successful, the SIU must move beyond the complaint-driven single provider cases that dominate so many units. Data Analysts and Scientists are needed for this. Depending on size and need, this can be a fractional FTE investment. You will find that it is worth its weight in gold (or pecan pie (my favorite)).

Statistics play a huge role in the success of an SIU. The use of statistical samples and the ability to extrapolate results across a defined universe multiplies the return-on-investment potential for SIUs. To do this, of course, you need the right tools and personnel. Software programs like the HHS OIG’s Rat-Stats are wonderful instruments to use to create defensible samples and be the basis for extrapolating results. But a tool is not a cure-all. SIUs should/must consider using Statisticians to, at least, review and approve the samples and extrapolations that are created. The results of cases based on sampling and extrapolated results are appealed at a far greater rate than simple claim-by-claim overpayments. An Investigator utilizing Rat-Stats, or other similar tools, can only go so far in defending their work. Having a Statistician on board will strengthen your findings and make them much more difficult to overturn. Again, a fractional hire or shared resource may be a good solution. In any event, it will be worth the investment.

These suggestions are part of our PI Day celebration because Advize wants all SIUs to succeed and have the programs in place to bring in their just desserts; in other words – a bigger piece of the pie.

Happy Pi Day.

By Matt Kochanski