Jack Price on building a top-notch SIU
FierceHealthPayer: AntiFraud spoke to Jack Price (pictured) about how payers can create high-performance special investigations units (SIU) to control fraud, waste and abuse. A former law enforcement officer, Price is a consultant with more than 20 years of experience developing, managing and leading SIUs in the life and health insurance industries.
FierceHealthPayer: AntiFraud: What do top-performing SIUs do that average or underperforming units don't?
Jack Price: Top-performing SIU operations have an adequate staff with expertise in several different areas of investigations or health insurance operations. If you just have a group of auditors or investigators who receive and handle referrals, the SIU will have to rely on expertise from other areas or they'll miss opportunities to enhance investigations or their results.
It's helpful to have diversified expertise within an SIU staff, including nurses, pharmacists and a physician if you can afford it. Typically, payers have a medical director or assign a physician to support the SIU, and that works. But it won't work if the doctor has so many other responsibilities that the SIU is an afterthought.
Consolidating fraud and abuse fighting into one business area has proven to be very effective; but some payers break the function apart rather than running a unified SIU operation.
In some organizations, the SIU only handles the worst of the worst, or the horrible fraud cases that come up. But there's also waste and abuse, and they're all closely related. If a payer fights waste and abuse through other departments and there's no communication between everyone, it hurts. Communication isn't as effective as it is when payers combine fraud, waste and abuse control in one operation.
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