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Special Investigative Units (SIUs) Services for MCOs: Support and Outsourcing

Medicare and Medicaid managed care organizations (MCOs) must ensure that their network providers are reputable and providing quality care with transparency and integrity. This is in the face of challenges arising from fraudulent or abusive providers that attempt to bill for services that were never actually performed or drugs that were not dispensed; misrepresent the procedures that were performed; and even solicit kickbacks for patient referrals.

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SIU Support Services

The Centers for Medicare & Medicaid Services (CMS) has mandated the implementation of an internal Special Investigation Unit (SIU) to address fraud and abuse risks. The purpose of SIU services is to create a partnership with state and federal law enforcement and regulatory agencies to detect, prevent, and correct instances of health care fraud. This is to be done by deploying trained professionals with expertise in data analysis, health care claims audit, and investigation to identify suspicious billing activities, stop or prevent fraudulent payments, and even aid in prosecutions of violators. Fraud detection and investigation is very complex and requires experienced professional expertise and this is nowhere truer than in the world of highly regulated programs of Medicare and Medicaid.

Finding and hiring professional staff with the necessary expertise can be difficult and expensive. An added problem is that depending on the size of the plan, the number cases provided to the SIUs at any given time are unpredictable. For those SIUs that only receive cases infrequently the skill level varies and the ability to plan resource allocation is difficult. The down-time may be high and the cost per case exorbitant, resulting in overall low efficiency. Accordingly, many managed care plans are not able to efficiently house the expertise and staff necessary to adequately detect and investigate cases.

SIU Outsourcing Services

Outsourcing SIU services or discrete functions has been the answer for many. Either approach can be a very cost-effective solution, especially where the SIU firm has the existing experience, knowledge, and expertise. The benefits can be significant in that internal audit outsourcing can:

  1. Improve fraud detection ability.
  2. Better manage the size and work load of the SIU staff.
  3. Eliminates the high cost of finding and training staff.
  4. Permits a health plan to augment existing staff.
  5. Offer to shift SIU duties to experts better equipped to do the work.
  6. Reduce costs that assist in the plan meet medical loss ratio requirements.
  7. Gain access to a variety of highly specialized fraud skills such as data analysis, claims sampling, investigative document review and interview techniques that are hard to fine and maintain.
  8. Engage expert staff using latest fraud detection and case management tools.
  9. Improve fraud recovery resulting in major cost savings and improved return on investment (ROI).

Strategic Management, under the direction of the former Department of Health and Human Services (DHHS) Inspector General provides professionals with experience and in depth understanding of health care fraud, the regulatory and compliance requirements within MCOs, as well as a long history of working with federal and state law enforcement agencies.

Our investigators had received and delivered training at the premier training venues, including the FBI Academy and the Federal Law Enforcement Training Center. In addition, our firm has data analysts, regulatory/legal analysts, auditors, and investigators with experience working with managed care organizations. Our skilled, credentialed management staff can also create investigative workflows to standardize and document processes related to your SIU services.

Strategic Management experts are able to collaborate in creating a fully staffed SIU team, or provide any necessary support for the SIU. This can be done easily, efficiently and on-demand, allowing internal staff to focus on core functions, best managed in-house.

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