“If you want different results, do not do the same things.”
— Albert Einstein
“If you want different results, do not do the same things.”
— Albert Einstein
Specialized Prepayment ABA Project Support
Mid-Size Plan 500K+ Lives
Their Challenge:
Our client was seeing a surge in concerning ABA billing and needed assistance identifying whether prepayment claim submissions were appropriate based on documentation.
The Results:
Integrity Advantage ABA SMEs went to work and identified the inappropriate billing behavior, assisting the plan in preventing improper payments on a prepayment basis.
Over $4M saved as a result of the collaboration between the Plan and Integrity Advantage in the first year.
We augment their current staff of CPC and RNs to conduct pre and post pay medical record reviews. This elimination of case backlog has allowed their SIU team to complete and identify more cases, and in turn increase recoveries.
FWA Program Buildout and Execution
Large Plan 2+ Million Lives
Their Challenge:
Our client needed to align their SIU with industry benchmarks and regulatory expectations. After completing and delivering an FWA Program Assessment and action plan, Integrity Advantage supported the implementation and execution of action items in collaboration with the plan.
The Results:
Restructured entire SIU program including job descriptions, goals, processes and training. Provided 1-1 mentoring of investigative and medical review staff.
63% Increase in number of investigations opened
7x Improvement in the quality and quantity of law enforcement referrals made
ROI improved to 4:1 after the full restructure and implementation was complete
Over $20M identified organizational losses due to new cases generated and risks
Pandemic FWA Strategy
National FEHB Plan
Their Challenge:
Knowing that the pandemic created a number of risk areas and opportunities for FWA, this plan wanted to take an aggressive approach to identifying FWA proactively.
The Results:
Integrity Advantage created a Pandemic Strategy identifying stakeholders, action steps and accountable team members as well as highlighting key areas to focus data mining efforts
Assisted in execution of the strategy by data mining for concerning trends
Within 1 month, delivered 6 new cases related to suspected Pandemic FWA schemes totaling nearly $500K in losses
Anti-Fraud Program for State Approval
Medicaid Managed Care Organization (MCO)
Their Challenge:
New MCO needed compliant processes to align with appropriate FWA program expectations including foundational anti-fraud plan, case tracking mechanism and compliant processes.
The Results:
Developed policies and processes based on industry best practices as well as compliant with Medicaid expectations
Assisted the plan in tracking all FWA work by creating an internal case tracking mechanism
Created comprehensive Anti-Fraud Plan which was granted state approval
FWA Clinical Investigative Support
Medicare Advantage Plan
Their Challenge:
Our client needed skilled FWA support to generate new cases, perform medical reviews and improve strategic focus on FWA identification
The Results:
Integrity Advantage created an annual work plan identifying core FWA risk areas
Identified new cases using their existing technology suite
Performed medical record reviews to assist plan in educating flagged providers
Home Health Record Review: State Medicaid
State Medicaid Agency
Their Challenge:
Questionable billing patterns related to Home Health services were observed in regard to Medicaid patients. Our team of experts was tasked with medical records reviews to determine if services were billed appropriately.
The Results:
Integrity Advantage identified multiple areas of concern related to the billed services (including issues related to service plans, documentation errors, and electronic visit verification.)
Services billed did not meet required documentation criteria.
Provided applicable guidance to the state plan for future reviews, including areas of education.