Interviews can make or break a health insurance fraud, waste and abuse investigation. So FierceHealthPayer:Anti-Fraud contacted Alanna M. Lavelle for insights on how payers can maximize the productivity of witness interviews and overpayment recovery meetings with providers.
Lavelle (pictured) is director of Enterprise Investigations at WellPoint and was an FBI agent for more than 24 years.
FierceHealthPayer: Anti-Fraud: How do you get interviewees to open up and volunteer information in fraud investigations?
Alanna Lavelle: Make the witness feel safe and comfortable. I use a friendly, nonadversarial tone. I often tell witnesses they're doing something that's both right and patriotic since they're helping not only a commercial payer but often the government save millions.
Interview setting is critical; don't interview complainants in the provider's office.
Whistleblowers have called our hotline to say they were fired because they accused a provider of committing fraud. And they're sitting in their kitchen and don't know what to do but they want to make a report. I may drive to their house to have coffee with them and they'll tell me fresh information. Or I'll meet them for lunch and we'll speak quietly in a booth.
FHPAF: How can fraud investigators improve interview note taking and documentation?
Lavelle: We have one individual who knows the case inside out prepare all documents and interview questions. Another investigator accompanies this person on the interview to take notes. So the lead investigator doesn't have to stop and jot things down; he or she can keep the interview moving.
FHPAF: How do you manage hostile or uncooperative people?
Lavelle: Learn to de-escalate. If you return hostility in kind, the situation escalates and you can't diffuse it. I use a calm, quiet tone and mirror interviewees' words.
If a case doesn't rise to the level of criminal intent to defraud, we'll try to settle it and recover the money. If providers say 'I'm really upset that you would accuse me of fraud,' I might respond: 'Accuse you of fraud? We haven't even used that word. This is nothing more than an interview. We just wanted to talk to you. This is very likely a billing error.'
At one meeting with a hostile provider and his attorney, my interviewer got right back in their faces. I told her to go print a policy. When she left the room, I diffused the situation by saying 'Let's start over. We began on the wrong foot.'
Remember: You don't want to cause abrasion, you don't want lawsuits, you don't want them digging their heels in. Doctors often thank us for treating them with dignity, for listening to their side of the story. If you treat them with respect and share intelligent conversation, you can clear up a lot. Most healthcare providers are honest; it's the fringe that's responsible for fraud.
But there are cases where not only can we prove intent to defraud, but providers have actually harmed patients. In these circumstances, we try to develop a witness case to refer to law enforcement.
FHPAF: Is it helpful to get signed statements?
Lavelle: It's a good practice. If you have interviewees sign a statement and you witness and notarize it, it locks in their statement a little better. If you just had a casual interview that you wrote up, interviewees could later say 'I didn't say any of that.'
FHPAF: What overpayment recovery meeting mistakes should special investigation unit professionals avoid?
Lavelle: The worst mistake is being unprepared, interviewing before you've done the necessary legwork and analysis. It's embarrassing if you accuse someone of overbilling without looking at medical policies or clinical guidelines. It's really bad when you're facing a doctor and you don't have your fact pattern correct. So do meticulous background work. We look at all the coding, medical policies and payments.
Sometimes providers bring coders, medical consultants and statisticians to overpayment recovery meetings. If they do this, have the same types of professionals on your side of the table.
We once met with a large hospital, and they had us sit in a waiting room for a long time before their people came in to negotiate. One of us looked down and noticed the phone light was green. They were monitoring our premeeting preparation! We reached over and hit that green light, and within a minute they all came in. Be aware of tactics like this.
Here's another: A provider's attorney left his briefcase in our conference room, and inside was his whole defense. And as soon as I spotted the brief case, I got a witness so we wouldn't be accused of touching anything in it. We guarded it with witnesses, locked it up and waited for a courier to retrieve it.
FHPAF: Are there best practices you can recommend for interviewing or negotiating settlements productively?
Lavelle: Once whistleblowers disclose information, if they're still working for the provider, they'll be nervous. Take care of them. Treat every witness with the utmost importance. Give them support, even if it means calling them at night to see how they're doing.
And here's a tip for cultivating witnesses: If you're at a provider's office doing an audit, I tell my investigators to be as professional as possible, to wear a suit, to be courteous and pass out business cards. I can almost guarantee that someone from the office will call you later with more information.
Prepare for provider defenses in overpayment recovery meetings. Say the provider is billing for something that's experimental but cloaking it with a conventional code. Expect the provider to tell you other payers cover the service. Anticipating that, I bring out copies of competitors' medical policies to show the provider that's not true. It's very compelling when you've done your homework.
I also prepare a bar chart showing these providers as outliers. I pull claims for all of their specialty-matched peers in that state, and I'll show the providers how much they made for a given procedure versus how much their peers made.
Because many employer groups have dollars at risk in the fraud pool, I tell providers that the money belongs to specific groups, and that payers are the guardians of their accounts. I'll ask providers if they'd like to face all these groups as litigants or if they want to settle with us on their behalf.
Editor's Note: This interview has been edited and condensed for clarity.