Dr Simon Peck
In our previous bulletins, we discussed in some detail the identification of Fraud, Waste and Abuse (FWA) in health insurance claims. When identifying FWA, challenges are mostly technical and related to data quality, processes and analytic capabilities.
After FWA has been identified, the game changes. We are met with a different challenge, one that has very little to do with our technical ability to filter through billions of datapoints or identify a suspect network of providers using advanced graph analysis techniques. The question is: “how to best tackle FWA after it has been identified?” The answer is not always obvious and involves a few different factors which we will explore in this article. In particular, we will look at the human element and how investigative teams can improve the chance that their recommendations are followed through.
I should note that the challenge can be simplified by having clearly defined processes in place for dealing with FWA, such as specific billing agreements or contractual recovery provisions.
To act or not to act
In deciding what to do with discovered FWA, the decision-maker needs to consider the well-being of patients, commercial interests of the company as well any relevant legal and regulatory frameworks. While doing so, the person will also (consciously or not) assess the impact their actions will have on relationships with friends, colleagues and customers. With these ‘human factors’ involved, the decision is often not obvious and can be inconsistent.
Some examples of the human factor include:
- Customer service staff are driven by customer satisfaction
- Complaints resolution staff must manage complaints with minimum fallout and without creating bad publicity.
- Procurement staff have ongoing relationships with providers.
- Sales relationship teams have ongoing relationships with corporate clients.
- Brokers bring in valuable business.
- Senior executives are risk averse and do not like litigation generally.
- If the fraudster is a member of staff, they will have friends, colleagues and people in the company who support them.
Many fraud investigation teams in healthcare share a common complaint: the biggest obstacles to recovery and efficient claim handling are not necessarily external. To tackle this, it is essential for a fraud team to understand that every fraudster is someone’s customer, someone’s business contact, even someone’s friend and these relationships may be important too. In some cases, paying the claim may be preferable to losing a customer, to avoid bad publicity, or even receiving poor feedback from existing customers.
When I started in this field many of the fraud investigations were curtailed to some degree by internal pressure. Sometimes reasonably, sometimes less so. I have heard stories of staff colluding with the subject of an investigation, and even know about a case where a fraud investigator was dismissed as a result of complaints made by the subject of an investigation. Whilst I haven’t personally had such experiences, these situations do arise in the industry every now and then.
It may surprise readers when I say that I actually understand this to some degree. Everything should be open to question and a degree of pragmatism is essential. Investigators must be accountable for their decisions (and their conduct), while still retaining the authority to carry out their work. It is a delicate balance.
Managing the human element
Given the complexity of FWA intervention decisions, it helps if we can simplify them and reduce the unpredictability of the human element. To that effect, management of internal stakeholders is key. When it comes to recovery, my strategy is often setting out deliberately to engage key stakeholders both inside and outside the company from the get-go. Simply by engaging with the stakeholders, they will be more receptive to my eventual recommendations and will be less inclined to dig in their heels in response to a process that otherwise would feel externally imposed.
As a result of this approach, I can say I have usually enjoyed broad support. Even though the support was never unquestioning nor 100%, my viewpoint was always considered seriously and all significant matters my team uncovered were usually dealt with.
Successfully engaging internal stakeholders involves understanding and navigating the culture and “psychology” of the company. Companies do have a dominant culture and working within this culture is paramount. Because company cultures are not homogeneous, I cannot give a one-size-fits-all solution. However, I can share some ideas that I successfully employed to obtain internal buy-in over the years.
Start at the top
In addition to my role in running a fraud team, I have done some consultancy both within multinational health insurers and for other companies. I always start by using a questionnaire to understand a client as well as possible. Without a doubt, the single key factor in success of a fraud team is the support of the Chief Executive. For many years, I worked closely with a CEO who understood our value and supported everything we did. I credit much of my success to this.
A person who influenced my thinking in the early days was Jim Gee – previously Managing Director of NHS Protect. One of the things I learned from him was the importance of both being and being seen to be professional. During my time as head of a fraud team, I insisted that all investigators had a professional qualification and that they worked under the supervision of a senior investigator until they had learned the core skillset we required.
Professional investigations are carried out in a manner which is lawful, fair, ethical and they set out to establish the truth not to achieve a specific aim.
Professional investigations give confidence to internal and external stakeholders and more importantly they produce a file of evidence suitable to use in court.
I have come across many individuals who believe they have an innate ability to investigate fraud. The unfortunate reality is that most of us do not: investigation skills have to be learned and practiced like everything else.
Stay within the risk appetite of your senior management
Maintaining the confidence of senior management is essential. Part of this is not taking them too far outside their comfort zone. Every once in a while, a fraud investigation teams uncovers huge problems with the potential to significantly impact company reputation and the bottom line. When you break the news and blood drains from faces all over the C-suite, you know you’re in for a ride. Nobody likes a bearer of bad news. Hence, before bearing such news, you best make sure that top management has confidence in you.
Some years ago, I investigated and took action against three very senior doctors in the UK. My team also exposed a network of payments from hospitals to doctors which resulted in a change in the law. The cases were difficult, very high profile, and with the potential to cause the company serious problems if the investigation and recovery were not properly managed. In each case, I carefully engaged with all the stakeholders, focusing on the strength of our evidence. If from time to time I felt that the matter was becoming challenging due to personal reason or internal politics, I turned the heat down for a while.
Throughout the process, I made sure not to say or do anything would dent the management’s confidence in me.
Ultimately, we were successful in all three cases. Apart from the targets of the investigation, hopefully the only one who had sleepless nights was me.
I learned early in my career that confrontation, whilst occasionally having its place, is usually not a sustainable long-term strategy. I made huge efforts to be polite and courteous and insisted my team did so. Courtesy costs nothing and the upside is huge. Arrogant or aggressive investigators achieve far less than those who are approachable and willing to listen and consider all points of view. Subjects of investigations frequently complain about those who are investigating them. The trick is not to give them ammunition – too many times I have seen the focus of an investigation shifted from the matter at hand to the conduct of the investigator. It is important not to react to provocation, threats, or emotional outbursts – I experienced all of these, the trick is to simply keep the conversation focused on the facts of the case.
Education, education, education – internal PR
I had an internal PR strategy from day 1 which was to educate the company as to the existence and risks posed by fraudulent behaviour, to teach them how to recognise it and to get them to buy into our success.
My team had a strategy of attending other departments’ meetings, cultivating friendships, and reinforcing our existing professional networks. I also engaged with managers of the main provider organisations and groups. Due to the circumstances of our professional interaction, I did not expect to become their best friend. However, we did establish a solid working relationship. I was once invited to give a presentation on “Fraud and Misbilling” at a British Medical Association conference. Being a topic of sensitive nature, the BMA did not in the end address my presentation in the official press release. However, judging by the conversations following the presentation, the message certainly resonated with the audience.
It is also good to remember those who pass on their concerns to us. As every fraud investigator knows, you cannot follow up on all leads. However, even when the investigation went nowhere, we would always give feedback to the people and teams who referred the cases in the first place. A personal call is of course best – a little recognition goes a long way!
Demonstrate and celebrate success
Production of KPIs is an essential part of managing a team. It is important to understand what management value and to show the team is working to achieve that aim. KPIs are annoying and can feel like a distraction from the work, but it is important to give them proper focus.
I also wrote regular articles in the staff newsletters and in the press to highlight the achievements of the team.
Consider the other person’s point of view
It is important to understand that whilst managing fraud is important to the fraud team, sales staff care about sales, customer service staff are motivated by customer satisfaction and management care about reputation and profit. These points of view are entirely legitimate. The successful team understands this and ensures that these stakeholders see their concerns are being taken seriously.
Remember this is a long game
Every fraud investigator has had to drop at least one case they feel strongly about which goes nowhere. A degree of pragmatism is essential. Whatever people may tell you, some problems are just too difficult to deal with. There are undoubtedly people with extensive connections who can pull strings that the rest of us cannot. Whilst these individuals may not be above the law, they are not held to the same standards as the rest of the population. In criminal cases, police must prioritise resources and may not accept cases against well-connected individuals without considerable prima facie evidence. The propensity for UK regulators to shy away from difficult problems is sadly also well documented. Nobody tells you this when you start, but everyone working in the field will tell you privately that this is also their experience. Sometimes you just have to let the matter go and be content with having done the best job you can.
There is no place here for grand gestures. Quite often, those who stick their heads too far above the parapet get shot down. There is not a single right course of action in such circumstances. In most cases it pays off to think carefully about the matter – unless the issue is particularly important, it is often best to live to fight another day.
Navigating the minefield of corporate culture is a difficult game. It is a skillset which is never taught but one which is essential to success. If the fraud team is seen as an obstruction to business, the team will face opposition at every turn. If the fraud team establish themselves as a respected part of the company, contributing to its financial success while protecting patients from harm, they will be successful. Arrogant obstructive and aggressive investigators do not last.
As always, I would love to hear your views on this – please send in your comments via our contact form.
Kirontech Health Insurance Platform (HIP) is custom built software suite to tackle Fraud, Waste and Abuse in Medical Insurance. Unlike traditional AI/ML software providers, we combine our software solution with an expert team of medical and fraud experts. Because of the nature of our engagement, we seamlessly integrate with your existing workflows. We do not replace in-house investigators or recovery experts, but instead empower them with the state-of-the-art tools and most comprehensive information available in the market.
In the spirit of this article, we fully recognise that when it comes to claim integrity management, technology is only part of the solution. Software without workflow engagement is obsolete the moment it is installed. That’s why our in-house experts work hand in hand with our customers to train them in innovative uses of technology, to find optimal ways of using HIP as part of their workflows, and to help you retain a competitive edge in an industry that is rapidly adopting innovative technologies.
Dr Simon Peck, Chief medical Advisor, Kirontech UK Ltd