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PROVIDER FRAUD
Proactive not reactive
Industry leading experts
Over $50 million in savings
Thousands of lien withdrawals
Bulk settlements & lien consolidations
Prosecutions to include CA’s largest provider fraud case in history
ArgusFirst represents industry leading expertise differentiating ourselves with proactive strategies against suspect providers vs. our competitors reactive out of the loop failures. While others claim to be able to handle provider fraud as a part of their “SIU”, the reality is their strategy is insufficient, inexperienced and a blackhole of their client’s data, money and results.
First, let’s begin explaining why our competitors fail with a reactive strategy. Time and time again, we have witnessed investigative companies and other SIU’s learn about a bad provider through others. Typically, this occurs when the District Attorney requests their company’s information for payment data regarding a provider. The “SIU” runs the reports and sends the information to the District Attorney hoping some day and magically they can get rid of that exposure. Meanwhile, claims examiners are having to negotiate and settle liens for much more than what should have ever been allowed.
What’s worse is there is no effective strategy to minimize current exposure or prepare a plan of action to resolve remaining liens in bulk. This occurs because they don’t have the experience or knowledge on how to do this. Additionally, they had no prior open investigation regarding a provider when asked to submit their data to law enforcement. Therefore, they don’t have the evidence to support a bill objection reason code when denying a suspect bill on the front-end.
Further, these providers have been bilking the industry for up to seven years or more before law enforcement asks for your data. We have worked the largest provider fraud cases in California history but, yet, it took over seven years before an indictment was handed down. The entire industry was paying these providers loads of money except for a few knowledgeable companies. Less than a handful of companies have a proactive strategy to stop these payments years before it becomes a criminal case and other “SIU’s” catch on when asked for their data.
As we all know, it is much easier to stop the flow of money on the front-end to bad providers than it is to recoup money already paid out years after the fact. It just doesn’t happen. So, does your “SIU” protect you against bad providers? Are they integrated with your bill review with supporting evidence to articulate a reason code to deny a suspect bill up front?
A PROACTIVE strategy against bad providers has many advantages to include millions of dollars in savings. Proven strategies over the years have resulted in over $50 million in savings while significantly reducing overall claims costs. These savings are obtained through bulk settlements with confidentiality agreements to never bill our client again. Thousands of lien withdrawals on claim files with providers walking away from millions of dollars in billables. In some instances, bad providers have paid money back as part of the bulk settlement. While some providers were luckily enough to avoid criminal prosecution and continue to bill the rest of insurance industry, they are no longer billing our clients.
There are also substantial unrealized savings in a proactive strategy. In our experience, getting rid on one bad provider to bill our client, comes with much more savings than that of one provider. For instance, getting rid of one bad medical clinic also eliminates all the ancillary services that clinic referred a claimant out to. That includes; diagnostic testing, chiropractic or acupuncture referrals, transportation and translation services, drug testing and others. Think about all the billing associated with one bad medical clinic disappearing because they no longer received those referrals, can bill on a lien basis and drive up your medical costs. Sometimes the savings by just eliminating one bad provider has much larger savings impact than realized.
The strategy also works exceptionally well at the WCAB. Lien hearing reps know which company will pay their liens and at what rate. Additionally, they know down to which claims examiner at these companies will pay their liens. Once they receive pushback (to all their liens) from a company, their willingness to negotiate grows. They will settle liens for less than 10% from our clients while they know they can get 30-40% from the rest of the industry. Their willingness to negotiate for substantially less is driven by the fact they are avoiding their PMK (Personal Most Knowledgeable) coming down to the WCAB and having to testify to our investigation results. If your “SIU” is not able to force PMK’s to justify their business practices under oath from their investigative results, your “SIU” not only doesn’t have a front-end proactive strategy, they don’t have a back-end defense strategy.
ArgusFirst’s ARMOR Program utilizes SPEAR, proprietary provider fraud investigative tools built on decades of experience, that can be integrated with any bill review platform through an EDI bridge.
