Helping stakeholders recognize and report potential fraud, waste and abuse is crucial to the success of payer anti-fraud efforts. But there's no one-size-fits-all training program to do this job, and building fraud awareness is ongoing work.
FierceHealthPayer: AntiFraud spoke to Darrell S. Langlois (pictured), vice president of compliance, privacy and fraud at Blue Cross and Blue Shield of Louisiana, about anti-fraud training offerings that engage stakeholders and contribute to the success of special investigations units.
FierceHealthPayer: AntiFraud: What types of anti-fraud training does your company provide to its special investigations unit and other staff?
Darrell Langlois: For the training aspect of our job, I consider not only formal training but the development of fraud awareness, because often we need to be reminded of something more than we need to be told how to do it. So we offer a myriad of ongoing training and awareness efforts.
We have a goal of 40 hours of training a year for employees who investigate fraud. We often surpass that goal by engaging with law enforcement to learn tactics that go along with law enforcement activity. For example, sometimes investigators find themselves in court and it's necessary to understand how the court system works. And since there's much to be learned about data analytics--which are all the rage in fraud fighting--we actively seek training in this area.
Our first training outreach to other staff is part of new employee orientation. Every new employee sits down with us on their first day for 30 to 35 minutes. We'll define fraud, talk about why fraud is important and the amount of money lost to it.
Every year, we offer employees computer-based training. This includes other topics--it's not solely anti-fraud--but fraud is always an important part of the program.
Corporate anti-fraud awareness efforts occur throughout the year. We provide specific tips on 3 x 5 cards, for example, that we color code and hand out to employees to display in their cubes. The tips refer to specific jobs such as enrollment or claims processing. We display anti-fraud message cards and reminders in the cafeteria and posters around the building and in elevators. And we have a tip-of-the year program that rewards employees for submitting fraud referrals.
FHP:AF: Do you offer anti-fraud training or information to executives and the board of directors?
Langlois: Our executives take the computer-based training provided for all staff. They get the same materials and must correctly answer the test questions.
We provide updates on significant fraud cases quarterly in a brief review with the board and senior management. We present data on specific cases and activities. While this may not sound like training, the reality is that for someone who doesn't touch anti-fraud work every day, this is an awareness builder. We're telling them about specific scenarios and what we've done to overcome them.
Listeners begin to understand the cases well enough to ask further questions in the future about what we'll do about different fraud schemes. So we count this as training. We believe it's of great value to the board, and we've been doing this for years. Moreover, our board views this section of the quarterly agenda as one of their favorites because of its significance.
FHP:AF: Does your company provide anti-fraud training to providers and customers? What are your best tips for reaching these audiences?
Langlois: To understand the many ways in which fraud is perpetrated by and impacts providers, you need to look at broad categories. One is billing, including coding, service volumes and choices made within a provider's office. And then you have the medical side, which involves whether a service is necessary, nonexperimental and consistent with good medical practice.
So our first, most generic method of provider training is distributing monthly newsletters geared to providers and their operational staff. Many times, issues can be avoided and/or remediated by working with the staff of a given provider, by making sure they're not making mistakes or allowing a coworker to make mistakes that may later give way to fraud, waste and abuse.
Newsletters address typical coding problems. And whenever a case raises an issue proven to be fraudulent or abusive, the newsletters address this issue with pointers such as "don't bill this code with that code," or "here's how to use modifiers correctly." Newsletters also address medical necessity issues.
Secondly, if we find problems with specific providers, we'll conduct on-site reviews in their offices. In the course of those reviews, we convey to the staff what choices on their part led to the problems. Many times, we also put this information in writing.
On the customer side, training starts with our website, where we tell customers about schemes to watch for. We have an ID theft document on our website that encourages people to be concerned about that. And we've even done some television shows where TV personalities interviewed us about fraud-related issues. We also issue press releases to heighten fraud awareness. And if a customer provides a significant fraud tip, we recognize the person though a gift.
It can be difficult to engage customers in fighting fraud if they're not in the middle of it or watching stories about it on the 6 o'clock news. But we've found that as long as we keep the material in front of our customers 24/7, the better it is.
We also work to help employer groups understand the costs of fraud. We actually sell our anti-fraud services to certain groups as an á-la-carte service.
FHP:AF: How do you measure the effectiveness of anti-fraud training?
Langlois: Employees must correctly answer 80 percent of the questions in our computer-based training. If they don't, they must retake the test to achieve 80 percent.
In a longer-term return view, we look at how many fraud and abuse tips we get and the number of cases generated through employees. Every year, we've had an excellent tip from an employee that resulted in a significant case. We make sure we're visible in the organization so people understand our message.
Probably the most significant measurement for senior management would be if, upon regulatory review, our regulators are satisfied with the level of training we've provided.
FHP:AF: Do you have any other insights that might help SIUs improve anti-fraud training programs?
Langlois: One pitfall in anti-fraud training is not tailoring it to audience needs. We don't send the same message to every audience we address, since one message won't resonate with all. Providers, for example, are very politically sensitive, so anti-fraud messages to them should be toned down a bit. Rather than pointing fingers, provider messaging requires a collaborative, cooperative tone.
Further, SIU directors should consider the potential for fraud to be committed within the organization. They shouldn't be myopic and only worry about fraud from external sources. Employees, for example, could think they're doing the right thing for the benefit of the company in a process that's highly regulated and involves government funding. But their actions could be construed by a regulator as a false claim. This problem could start as a simple decision with no ill intent on anyone's part; but if it these actions go on over time, they can cause problems.
Finally, training should help create an organizational culture of high integrity that sends the message that if you see something [that looks like a problem], say something.
Editor's Note: This interview has been edited and condensed for length and clarity.