Who Should Be Responsible for Health Care Payment Integrity?

Health care payers typically focus intently on assuring that they are paying the right health care providers for the goods and services that they should pay for, for the correct price, and for the care of the members or beneficiaries who are entitled to these benefits.  Given the negative impact of fraud, waste and abuse on health care, it’s in every payer’s interest to focus on these problems too.

But who should the payer task with this responsibility?

Here are four examples of how we have seen payers assign responsibility for payment integrity:

• In a recent post we described the experience of a payer who had suffered a significant fraud loss while their one SIU employee was away during the Christmas – New Year’s holiday. This payer had an internal payment integrity program, although one that was limited.  We have also worked with payers with sophisticated internal payment integrity programs.
• In government-funded health care insurance programs, and for some commercial health care payers around the world, an administrator may be responsible for payment integrity. Note that if the administrator makes most of their money from adjudication (assessing) and payment of claims, they are also typically required to fight fraud, but don’t be surprised if the administrator is not as interested in mitigation of losses to waste and abuse.
• A third party may be responsible for payment integrity. We have encountered “boots on the ground” vendors who have a law enforcement point of view, and we have also worked with vendors who offer outsourced SIU or Forensics services.  Be aware that “boots on the ground” vendors may not be able to help you mitigate losses to waste and abuse.
• There may be no “fraud shop” at all. We have encountered payers who don’t seem to believe that they have a fraud problem.  Payment integrity projects that we undertake for this kind of payer typically reveal important insights.

Which is the best approach for you? We recommend that you consider the following things:

• Recognize that payment integrity includes attention to a range of types of losses, not just fraud, but also to waste (unintentional or unnecessary payment) and abuse (manipulation).
• Fraud is traditionally addressed by the SIU or Forensics. Engage your stakeholders to mitigate losses to waste and abuse.
• Emphasize that it’s more important to identify and solve problems than it is to assign blame. Emphasis on blame will deprive you of many opportunities for improvement because people will deny that problems exist.
• Choose great people and assure that they have great resources. Choose people or vendor(s) with strong knowledge of your health care industry and deep understanding of your claims adjudication (assessing) system and payment policy.  Give them great tools to work with.
• Be prepared for change because the people who inappropriately take your money are entrepreneurial.

We welcome your comments.  Stay tuned for our next blog on health care fraud, waste and abuse.