Much has been written and said about war. Bookstores and libraries (remember those?) are full of tomes about real battles and the heroes that fought in them. They also have shelves of self-help guides that somehow stretch metaphors to make life’s everyday struggles into warfare. Strategy games like Risk, chess, Stratego, all liken themselves to warfare. People have wars of words. Television shows thrive on the warfare theme – Neighbor wars, Parking wars, storage wars, etc. etc. Ad naseum.

So, if everything is a war, what isn’t? The easy answer is that a war isn’t a war when everybody’s on the same side. Immanuel Kant was a philosopher, but he was also a historian. (and for the Monty Python fans, he was also a real piss ant who was very rarely stable). His theory about nations and wars was that the only way to stop people from destroying themselves was to show them that it was in the best interest of both sides to stop (remember “War Games”?) It was only when the game realized it couldn’t win without destroying itself that it stopped playing. The same is true of humankind. A human will always think first of what is in their own self-interest. Self interest will inevitably lead to conflict as people’s narrow self-interests conflict. It is only when people realize that their self-interest must be in line with everyone else’s that the conflicts stop.

This same philosophy plays out in health care fraud investigations.

In keeping with Advize’s theme on negotiating with providers and the “Art of War”, I posture that a well planned and thoughtful settlement with a provider is not a war, but a conversation where both parties want the same thing.

Like everything else involving an investigation or audit, a settlement negotiation must be carefully planned. The investigator/auditor must know their facts, must be able to strongly support their findings, they must KNOW that their determinations are right, and they must have the supporting evidence to back them up. They must negotiate from a position of strength.

The provider comes into the negotiations knowing that they are right; that no one from an insurance company can tell them how to run their business or take care of their patients.

Sounds like a war is going to break out, right?

Not absolutely.

Let’s start with the premise that the only reason there is going to be a negotiation is because this provider isn’t a felon. Otherwise, the case would be in a different venue. The audit has shown that there are mistakes, oversights, perhaps negligence or misunderstandings of the policies and regulations. The provider did not kidnap the Lindberg baby. So, you must start with the premise that the provider is not the devil, and these negotiations are being conducted to right a very correctable wrong.

From there, the job of the investigator is two-fold. You must show the provider that your case is strong and – perhaps more importantly – you also must show them that resolving the case this way is in the provider’s best interest. Your best negotiating tactic is to demonstrate that you found a problem and you are going to help the provider fix it before it escalates into something worse. You must show them their mistakes but also show them how to fix them – educate them on process improvements, provide clearer understanding of the rules and regulations, become a partner with them in making them a better participant in the plan. Show them that following your lead will result in less time wasted and less money lost to future audits (or worse). Most providers just want to be paid fairly for the work they do. Show them how you have that same goal.

Negotiations are ripe for conflict but, going in with the right perspective, the right amount of preparation and a true belief that you and the provider want the same result, the conflict does not have to become a war.

By Matt Kochanski

Interested in mastering the art of negotiation for investigators? Join us for our March webinar happening Tuesday, 3/12 at 1 PM ET on LinkedIn and YouTube. Please register here.