November 14, 2023

It’s like sweeps week at Advize, but instead of the characters of SVU appearing on Law and Order, Eric and Matt blend their respective blogs into a new theme – the Fraud Hunters’ Union.

Last week, Eric had the opportunity to present at the Annual Training Conference (ATC) hosted by the National Healthcare Anti-Fraud Association (NHCAA) while Matt stayed back and minded the shop. This year’s ATC was held in Dallas, Texas, and was one of the more well-attended conferences (likely due to Matt not being there). Eric has been an attendee and presenter for over 20 years, and it’s always a great opportunity for like-minded individuals to meet, collaborate, and discuss the latest and greatest in FWA schemes, FWA detection tools, and the successes of the FWA community.

Eric presented with one of Advize’s client payer SIU directors on the importance of public-private partnerships (the interaction between law enforcement and SIU communities) and how that collaboration can generate high-quality leads for the law enforcement community. While this presentation was niche, both in its audience and discussion points (geared toward the SIU management community), it was extremely well-attended, with a dynamic audience that was highly engaged in the discussion. The biggest takeaway was the realization that the law enforcement and SIU communities are more aligned in their investigative focus than previously believed. We conducted a simple and unscientific survey of both law enforcement and SIU investigative groups. The results clearly reflected that the alignment on goals was similar, but more importantly, the SIU mission and internal processes are areas from which the law enforcement community can learn a lot. Matt, being an old dog, fondly remembers his days as a Special Agent when he spent many hours within the SIU unit of the Medicare carrier, learning about their work priorities, resources, and capabilities. Matt learned an incredible amount about claims processing, the medical review process, data analytics, and case prioritization from the myriad of people he met during those days – both verifying and illustrating Eric’s point about the importance of communication, mutual understanding, and similar missions and goals.

While the SIU community is often slighted regarding the lack of information provided by the law enforcement community about the status of an accepted referral, the SIU community can also provide education and training to the law enforcement community on how internal SIU processes work. We learned that internal processes can be cumbersome, and delays in providing information to the law enforcement community can be frustrating. Furthermore, the law enforcement community may not be aware of internal or regulatory reporting requirements that an SIU needs to follow, and such reporting may lead to greater coordination between the two groups. When Eric was at the OIG, he was regularly contacted by SIU investigators about the status of cases, even when there was no additional information he could disclose. It became frustrating, being called month after month for updates on the status of a particular case. What has been learned since entering the world of SIU consulting and advising is that many SIU groups are required to provide updates to their case files and ongoing updates to state entities and regulators on the status of referred cases. Although Eric could not provide additional information due to the sensitive nature of an investigation, had he known that this was part of the operation of the SIU, his frustrations would have at least been tempered.

While with the UPIC, Matt saw the other side of that coin. Matt and other UPIC managers made multiple visits to the OIG Regional and Field Offices. The purpose of these visits was to learn more about each other. The UPIC learned the OIG’s priorities – what types of referrals they wanted and, perhaps more importantly, what cases they did not want to see. They also learned what information was important in a referral and why – many times, it felt like the referral was going into a black hole. The OIGs were provided information about UPIC data studies, pending referrals, and updates on issues such as resources available for OIG-requested medical reviews. These visits were an attempt to build the dialogue that Eric spoke of at the NHCAA.

Eric’s colleague, Ashlee Heath, joined him at the conference. In her blog, ‘Natural Curiosity: So, what’s new in healthcare fraud?’ she delves into the heart of healthcare fraud and takes you behind the scenes, unraveling the latest trends. With a decade of triumphs fighting fraud, she reflects on the unique curiosity that defines a successful investigator. Click here to immerse yourself in her blog; her perspective will lead you to understand what it takes to thrive in this field.

Overall, the conference, as always, is a well-planned event. Presentation attendance can vary greatly based on the targeted audience, time slot, competing sessions, and (frankly) whether it is nice outside or not. It was surprising to see the large number of people attending Eric’s session. After the presentation, Eric returned to the Advize vendor booth, where he was approached by numerous attendees who sat in on the presentation and provided positive feedback on the topic presented. If you present, you know that it can be a very satisfying experience, and receiving positive feedback on your presentation is the most rewarding part of the experience. Eric looks forward to continuing to speak on various topics in the FWA space and growing Advize’s network and footprint in this industry.

See you all next year in NOLA.

By Eric Rubenstein and Matt Kochanski

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