The Presidents Management Agenda (PMA) has inspired many a spirited conversation since it was released in March 2018, and with good reason. The measures it has introduced—intended to modernize the federal government in 14 key areas that enhance its ability to deliver mission outcomes, provide excellent service and effectively steward taxpayer dollars—have already had wide-ranging, positive impacts.

Two points specifically called out in the PMA’s cross-agency priorities—implementing better technology and processes to get payments right the first time and reducing associated costs should an incorrect payment be made—are vital to helping solve challenges government-wide.

For example, criminals have many routes by which they can steal from the healthcare system, from old-fashioned insurance fraud to sophisticated cybercrime techniques. The Global Health Care Anti-Fraud Network (GHCAN) reports that as much as $260 billion—approximately 6 percent of global health care spending—is lost to fraud each year. These losses drive up the costs of care and take away funds that otherwise could be used to treat patients.

With that in mind, here is a closer look at the key areas in the medical claims transactions process that healthcare payers can look to address using advanced technology and best practices:

• Pre-pay: Payers should implement systems and policies to ensure the amount about to be paid is correct. It should include semi-complex audits to allow for an improper payment review and to expedite the recovery process.
• Post-pay: After payments are made, incorrect payment amounts should be identified and addressed quickly by both the payer and the healthcare provider, with payment adjustments—refunds or additional payments—issued as soon as they are discovered and verified.
• Social media protection: Cybercrime often begins in social media, with tactics such as targeted phishing attacks, credential compromise, data exfiltration and brand hijacking. Diverse data sources and artificial intelligence-based analysis can provide organizations with instant identification of potential fraud and impersonations and institute automatic takedown procedures of offending posts, messages and accounts to help limit exposure.
• Reimbursement services: Such services help protect an organization’s future state. Data gathered throughout the recovery audit process is used to recommend changes to the payer. These new wrinkles—whether they be in policy, direction or billing—are intended to reduce the number of improperly submitted claims. This helps the organization generate as many recovery dollars as possible through improper payment audits, while simultaneously re-emphasizing or implementing policy changes to avoid making the same mistakes.

CGI’s end-to-end fraud, waste and abuse solution, CGI ProperPay, incorporates these capabilities through years of industry experience, from serving as one of the four permanent Medicare Recovery audit contractor firms, covering seven states and 8.5 million beneficiaries, and from performing reviews and audits on behalf of federal, state and commercial payers. Our claims audit and recovery services have been used to audit approximately 30 million covered lives.

Using our solutions and services, CGI has recovered more than $2.8 billion in improper medical and pharmacy payments for these clients, and regularly helps them achieve cost savings rates in excess of 40 percent (with an appeal uphold rate of greater than 93 percent).

At the Healthcare Information and Management Systems Society (HIMSS) Conference in Orlando, Florida, on February 14, I will be presenting a session titled “Protect Scarce Medical Dollars Using Social Media Monitoring.”

While no solution will ever completely eliminate fraud, waste and abuse in healthcare, we offer a holistic approach to helping keep it in check. For more information please, visit our HIMSS19 event page.

For more on ProperPay, download the brochure "CGI ProperPay: Fraud, Waste and Abuse Solution and Services for Healthcare Payers."