CHALLENGE

A national behavior health insurer had an established fraud, waste, and abuse organization that was staffed by individuals across the nation. The organization had not had a leader for an extended period of time. The insurer was facing continued risks from the lack of leadership, including the loss of key personnel, overpayments to providers, and a lack of consistency in terms of policies, processes, and procedures across the company. In preparation for the arrival of a new leader, the executive leadership wanted to have an assessment of the function to identify specific key areas for improvements and recommended next steps.
The insurer needed an objective assessment to be conducted by an experienced fraud, waste, and abuse professional who could quickly identify opportunities for improvement, including those that could be instituted quickly.

SERVICES

Advanta provided an experienced operational manager with fraud, waste, and abuse experience who:

  • Conducted a 4-week assessment of the fraud, waste, and abuse capability
  • Collected performance data
  • Interviewed key management and line staff
  • Reviewed existing documentation
  • Observed operations
  • Compared performance data to national benchmarks and analyzed the comparison
  • Analyzed interview and observational data against industry practice and combined that with our experience to identify improvements
  • Prepared a grid depicting people, process, and technology improvement opportunities
  • Reviewed the grid with management; prioritized the opportunities, including “easy hits” (quick/simple changes requiring limited resources – people, funds, technology, and elapsed time)
  • Obtained approval for assessment results (recommended next steps were documented, reviewed and approved)
  • Advanta staff implemented a series of “easy hits” that had been approved by the responsible executive. A major “easy hit’ was the creation of a performance dashboard to measure and monitor the effectiveness of detection efforts. The dashboard was updated daily and utilized by the function’s management to prioritize work and redeploy staff as necessary.

RESULT

Management was able to provide a clear and realistic view of the organization to the new leader. The assessment provided greater transparency in terms of the division’s current performance as well as the tools to monitor ongoing activity. After the new leader was hired, Advanta documented the results of the “easy hits” implementation and reviewed the project’s work and successful changes with the leader.