Prevention Measures

•  Creating a clear and concise compliance handbook
• Implementing written policies and a code of conduct that outline compliance expectations
• Designating a compliance officer and oversight committee
• Providing comprehensive training and education on compliance issues, fraud, waste, and abuse
• Establishing robust prepayment review processes, including claims editing systems and eligibility verification

Detection Capabilities 

• Investing in software and services that review payments post payment and prepayment
• Leveraging advanced analytics and artificial intelligence to identify aberrant billing patterns and potential fraud
• Conducting data mining and audits
• Implementing a confidential reporting hotline for compliance issues
• Performing ongoing monitoring and auditing of compliance risks

Investigation and Corrective Action

• Developing procedures for investigating potential fraud or abuse cases
• Referring suspected fraud to appropriate law enforcement agencies
• Implementing disciplinary policies for non-compliance
• Recovering overpayments and addressing improper payments

Managed Care Oversight

•  Requiring managed care organizations to have fraud detection and prevention procedures
• Conducting periodic reviews of managed care program integrity operations
• Providing managed care compliance toolkits and guidance

Collaboration and Partnerships

• Coordinating with federal and state agencies on program integrity efforts
• Engaging providers through education and outreach on proper billing practices
• Fostering a culture of compliance throughout the organization

Continuous Improvement

• Regularly assessing and updating program integrity strategies
• Staying current with evolving fraud schemes and regulatory requirements
• Investing in innovative technologies and analytics capabilities

By implementing these key components, health plans can develop a comprehensive program integrity initiative that effectively prevents, detects, and addresses fraud, waste, and abuse while ensuring compliance with regulations and protecting resources.