Policies for the digital era

Clear, current and discoverable policies can help today’s program integrity investigators fight fraud, waste and abuse

By and Lindsey Phelps | 2 minute read | January 20, 2021

Woman shares data on her tablet with a man in an office setting.

Fighting fraud, waste and abuse (FWA) is an evolving task in health and human services. When rules are confusing or conflict with one another, they create gray areas where healthcare providers can intentionally or unintentionally contribute to the huge waste in the U.S. healthcare system.

As health and human services undergo a digital transformation, policymaking must also modernize. We have worked with several public and state agencies that are eager for policies that have caught up to health and human services in the digital era. They’re looking for policies that are:

  • Clear. When working to fight FWA, investigators need clarity. Payer-specific policies must not conflict with state and federal regulations or other existing sources of policy but must be specific enough for investigators to audit to ensure policy compliance. Ambiguous or conflicting policy language results in unenforceable policies, lost opportunities to recover overpayments, and “loopholes” that fraudulent providers can exploit.
    For example, let’s say a policy allows up to 30 outpatient mental health visits per year. Does that mean per calendar year or per rolling 12-month time period? Is a member restricted to 30 visits per provider or is it 30 visits regardless of provider? Can the member receive more services if prior authorization is obtained? Clear policies will have anticipated questions like these, saving confusion for investigators down the road.
  • Current. Services, financial models, diagnostic and procedural codes, as well as technical capabilities are rapidly advancing in healthcare. Policymakers must adapt to these changes to win the fight against FWA. For example, personal care services were particularly vulnerable to fraud, which is why the Centers for Medicare & Medicaid Services (CMS) enacted electronic verifications for checks and balances to help reduce incidences. Other emerging areas – such as non-emergency medical transportation and genetic testing – are examples of areas where policy needs to evolve to help manage new entrants to the field.
  • Discoverable. When program integrity analysts and investigators can quickly understand and enforce policies, they will be able to better identify and address FWA. In the digital era, there are more technologies that can help investigators review and interpret volumes of policy documentation – but policies must be written in a way that can be more easily translated into queries that can help identify policy violations. Policies written this way can enable more automatic detection of policy violation in the data, if the policies can be linked to claims data.

Program integrity analysts and investigators can be more efficient and effective with clear, current and discoverable policies. As the workforce continues to turnover in the field, it’s imperative that we give them the tools and policy knowledge they need to be successful.