thinking inside the box with a provider decision quadrant

For many years and with limited special investigative unit (SIU) resources, the fight against fraud, waste, and abuse (FWA) has dictated the prioritization of only the most egregious and expensive cases—those that, if successfully investigated, could be expected to deliver the most significant return. But this can lead to underplaying true positives or overplaying false positives—all while aberrant providers at lower levels of dollar exposure continue to get away with fraudulent activity.

So how can SIUs ensure their limited resources are being put to their best use?

The provider decision quadrant is a visual decision-making framework that can help a health plan increase both its SIU’s operational efficiency and claim payment accuracy without adding staff. This two-dimensional model allows a plan’s SIU to take meaningful provider action by developing actionable leads, prioritizing potential cases for evaluation, and making decisions earlier in the investigation process.

Download our white paper to learn more.

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view our white paper