A Love Letter to Medical Reviewers and Investigators
A Love Letter to Medical Reviewers and Investigators
Dear Medical Reviewers and Investigators,
We LOVE collaboration. Strong fraud, waste, and abuse (FWA) outcomes don’t happen in silos, and few partnerships are more critical than the one between Medical Review and Investigations. While these roles require different skill sets, the work in deeply interconnected, with each team relying on the other to move cases forward and achieve meaningful, defensible outcomes.
Across programs and organizations, this relationship has been seamless at times and challenging at others. Different perspectives and priorities can create friction, even when everyone is working toward the same goal. The good news? Medical Reviewers and Investigators have more in common than they may realize, starting with a shared commitment to detect, prevent, and reduce healthcare FWA.
So, in the spirit of Valentine’s Day, our February tradition of writing love letters continues. Instead of one love letter, there are two: one from Investigators to Medical Review, and one from Medical Review to Investigators. Both are grounded in respect, partnership, and a shared mission to protect members, strengthen programs, and uphold integrity. These letters reflect insights gathered from Medical Review and Investigation professionals at Integrity Advantage. Here’s what they had to say...
PART 1: To Med Review, From Investigations
Dear Medical Review Friends,
This is our love letter to you - the clinical and coding experts who bring credibility, clarity, and confidence to our work, even when the path to a final determination isn’t always straightforward. Simply put, investigations are stronger because of you.
1. It Starts with Trust and Acting Like One Team.
What we value most is the trust and respect that show up when we truly operate as one team. When investigations and medical review move beyond separate functions and toward shared ownership of outcomes, the work gets better. We see greater efficiency in workflows and case results leading to actionable solutions. Your ability to step back and see the big picture helps us prioritize appropriately, focus our efforts, and move closer to our collective goal of freeing up investigative resources to do what they do best (#FreetheSIU).
2. Early Collaboration Saves Time (and Everyone’s Sanity).
Some of our best work happens when collaboration starts early. When medical reviewers are engaged up front to discuss the context around the referral and the investigative theory, reviews become more targeted and meaningful. Early conversations help prevent rework, reduce back-and-forth, and keep cases moving forward. Ongoing communication, especially when questions arise or findings evolve, can be the difference between a stalled case and a strong one.
3. Clinical Clarity Is What Moves Cases Forward.
Your clinical insight is one of the most powerful tools in an investigation. Clear rationale, constructive feedback, and well-written summaries don’t just close cases, they strengthen them. When your conclusions are clearly articulated and consistently structured, they support downstream decisions, provider education efforts, and external scrutiny. Consistency in format, content, and documentation means less time reworking deliverables and more time focused on meaningful analysis. In short, clarity doesn’t just help investigators, it helps the entire program stand behind the work.
4. We Recognize Your Love-Hate for Excel.
We recognize your relationship with Excel can be…complicated. It safeguards your findings and anchors every step that follows. Yet one rogue filter or an unexpected sort can undo hours of thoughtful work. While we promise not to turn this into a lesson on pivots, filters, or macros, we’re always here to partner on approaches that make Excel easier to navigate and more supportive of the incredible work you do.
With appreciation, Your Investigation Partners
PART 2: To Investigations, From Med Review
Dear Investigative Friends,
This is our love letter to you - the dedicated investigators, whose work lays the foundation for strong, well-supported reviews and outcomes. Your work is critical, and we see the time, thought, and strategy that go into every case. While our roles are very different and require different skills sets, each is equally important in making sure cases are defensible, accurate, and actionable. We couldn’t do this without you.
1. Set Us Up to Succeed.
Setting us up for success starts with clear and complete information. Well-defined allegations, complete lead-gen packages, and all the relevant data (diagnosis codes, lines of business, units, place of service, etc.) make reviews faster, more thorough, and more effective. If you have already found something, like a resource or insight that supports the allegation, share it! Do not make us dig for the gold you have already uncovered. The more context we have from the start, the faster we can move and the higher the return on investment of a review.
2. Communicate and Celebrate Wins.
Communication is key. We want to know your findings, and we hope you will also engage with ours. Collaboration makes both sides stronger, and when departments operate in silos, everyone loses. We love learning about the end result! We put in a lot of work to support your allegations and identify additional issues so recoupments and other case outcomes matter to us. Let’s celebrate successes and strengthen the partnership for the next case!
3. Complex Reviews Need Love, Too.
We understand that some reviews are beasts: multiple lines of business, large timeframes, or massive amounts of CPT codes. These reviews are complex and require significant time to research properly, which leads to longer turnaround times. Whenever possible, breaking up large reviews or providing context around why a review is extensive helps us plan and execute more effectively.
4. A Little Education Goes a Long Way.
Related to the complexity of reviews, we would love some insight on why certain reviews are larger in scope than others. A little high-level understanding of sampling, lookback periods, and how reviews are structured can make the ‘monster review’ feel more manageable to us.
With appreciation, Your Medical Review Partners
Aside from the individual perspectives, this exercise proved there are more shared perspectives than differences among the two teams.
Shared Perspectives Between the Two Teams:
Share expertise & unique insights.
Recommend efficiencies in the process.
When you are unsure, ask.
Remember, we are ONE team!
Understand the bigger picture.
Lead with mutual trust & respect.
Collaborate and communicate.
Don’t let work be siloed.
Together, these two love letters are a reminder that while Medical Review and Investigations may approach cases from different angles, their goals are one and the same. By taking the time to understand each other’s perspectives, share context, and communicate openly, you not only make your work more effective but also build a partnership that benefits everyone. This Valentine’s season, we celebrate the collaboration, trust, and expertise that make our teams and our programs stronger.
With more than 30 years of experience supporting payers, the team at Integrity Advantage provides healthcare fraud, waste and abuse consulting, outsourced investigations and medical record reviews for Special Investigations Units and other organizations fighting healthcare fraud. We are a certified Women’s Business Enterprise (WBE) and an Economically Disadvantaged Woman Owned Small Business (EDWOSB).
For more information click below, call us at 866-644-7799 or email info@integrityadvantage.com.