Law Enforcement’s Role in Commercial Health Plans:
A Critical Force Against Fraud
Fighting fraud, waste, and abuse is a mission critical to maintaining the integrity of our health system. Commercial health plans are particularly vulnerable to FWA, and with billions at stake, they are increasingly turning to Special Investigation Units (SIUs) staffed by professionals with backgrounds in law enforcement. But what is it about law enforcement skills that makes such a profound difference in identifying and curbing healthcare fraud?
Law enforcement professionals bring a unique set of investigative and analytical skills to SIU roles. Their training prepares them to navigate the layered complexities of healthcare cases, especially those involving FWA.
In traditional law enforcement, every detail is carefully documented, evidence is gathered with precision, and cases are built methodically, often over long periods, to withstand scrutiny in court. It’s exactly this discipline, combined with a focus on accountability, that translates seamlessly into the investigation of healthcare fraud.
As Carey Mead, an SIU Manager at Advize Health, points out, “Law enforcement professionals are equipped with a process-oriented mindset that spans from the initial complaint to the courtroom.” They’re not only skilled in gathering and analyzing evidence but also trained to see patterns that might go unnoticed by those without investigative backgrounds.
So, what does this look like in practice? Consider the challenge of identifying aberrant behaviors in healthcare data. Healthcare fraud isn’t always obvious; it’s rarely a simple case of overbilling or duplicate billing. Instead, FWA often lurks in patterns: unusual spikes in billing, consistent coding errors, or claims for procedures that don’t align with the patient’s history. Detecting these patterns requires a keen eye, a familiarity with regulatory frameworks, and the ability to see discrepancies as clues to a larger scheme. Law enforcement professionals trained in fraud detection bring a meticulous, investigative approach, pairing evidence-based techniques with data interpretation to trace these patterns back to their source.
Carey emphasizes how understanding “the totality of the process” is essential in healthcare fraud investigations. Law enforcement professionals know that behind every piece of fraudulent data is a perpetrator with motives, behaviors, and patterns that can be traced. For example, they excel at conducting interviews, gathering information, and crafting questions that reveal discrepancies and inconsistencies, ultimately strengthening the case against fraud.
Recently, Carey shared a specific example of the impact that law enforcement training brings to SIU roles. “The impact someone trained in law enforcement provides in understanding the totality of their actions on an investigation is unparalleled. Because of my years of exposure and collaboration, I am able to leverage my background to assist in the delivery of information and to address responses or questions about valid findings effectively. Being able to present findings to providers and plans in a way that demonstrates how they can maximize their return on investment creates a strong foundation for collaboration and drives effective outcomes. Leveraging both worlds makes healthcare stronger.”
But law enforcement’s role in SIUs goes beyond just catching perpetrators. It’s also about prevention and education. With their extensive experience in building cases, law enforcement professionals are adept at creating robust investigative referrals. Their knowledge of what will hold up in court means they can create compelling, clear cases that lead to successful recoveries. In doing so, they not only curb fraud but also help educate others within the healthcare industry about patterns of fraud and ways to detect it.
This insight into healthcare fraud investigations begs us to ask broader questions: How can the healthcare industry better leverage these skills to prevent fraud on a larger scale? And as FWA schemes become more sophisticated, what additional training or resources should be made available to healthcare professionals to complement law enforcement’s efforts?
Law enforcement professionals are vital in creating a healthcare system rooted in transparency, trust, and accountability. By integrating their skills, healthcare companies are better equipped to protect commercial health plans from those who exploit the system. In turn, this not only safeguards billions in resources but also helps uphold the integrity of healthcare—a mission that impacts every patient and provider across the country.