What do we mean when we say:
We’ve been asked this question a lot this year. Think about it…. Think about all the things that the Special Investigations Unit (SIU) or a fraud, waste and abuse (FWA) team does, or should do for that matter. There’s almost no limit to the variety of things the SIU might see within a health plan. Things that only the SIU might know to question.
#FreeTheSIU is our way of saying “GET OUT OF YOUR BOX” and share the ways your knowledge and insight can help the organization.
How?
Consider this:
During work with a payer, we flagged and investigated pre-authorized services for several providers. Upon review, we found that services weren’t rendered as pre-authorized. We see this often….. Providers as well as health plan staff were pushing back because the services had been pre-authorized… and they expected them to be paid. But, as we all know, pre-authorization is not a guarantee of payment. We requested to see the contract for the pre-auth vendor. We also had a discussion with the internal team who managed the relationship with that vendor. What we learned was that the vendor was not requesting the appropriate documentation when pre-authorizing services. This issue amounted to millions of dollars for this particular plan. Without the SIU asking questions and initiating action, the issue might have continued undetected. The SIU helped prevent millions more from being lost.
The SIU has insight into so many facets of how a payer works, but what we tend to see is the SIU operating in a box.
Is that because….
- They don't want to get out of their box?
- They are told they can't get out of their box?
- They don't know how to get out of their box?
Often there is a misconception that SIU work should be kept ‘quiet’ from the rest of the company.
Not so. Sure, maybe if they’re working an internal or confidential case, that would need to be kept under wraps. But many payers don’t recognize the immense value that can be found in this group of analysts, investigators, coders and clinicians.
SIU handles hotline referrals, emails from internal teams (like medical management), training, mining for new trends and schemes, working with claims, interacting with call center staff to provide guidance…. and the list goes on.
So this is our public service announcement - to #FreeTheSIU
Let them out and let them show how they can help prevent improper payments, identify inefficiencies within the organization and improve the care members get.
Are you a member of an SIU? If so, you’ll be astonished at how much value you bring to the table.