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The Culture and Logistics Of Establishing A Special Investigations Unit (SIU) William J. Mahon

The Culture and Logistics Of Establishing A Special Investigations Unit (SIU) William J. Mahon The Mahon Consulting Group, LLC Health Insurance Counter Fraud Group Annual Conference November 7, 2013. Why A Formal SIU?.

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The Culture and Logistics Of Establishing A Special Investigations Unit (SIU) William J. Mahon

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  1. The Culture and Logistics Of Establishing A Special Investigations Unit (SIU) William J. Mahon The Mahon Consulting Group, LLC Health Insurance Counter Fraud Group Annual Conference November 7, 2013

  2. Why A Formal SIU? • Vehicle for active—not solely reactive—response to the organization’s inherent exposure to fraud • Nucleus of the organization’s formalized. . . structured. . . ongoing. . . counter-fraud functions • Detection • Investigation • Resolution • Prevention • Focal point of these essential functions visible to rest of the organization and to external constituencies • Vital resource for internal and external parties

  3. The Anti-Fraud Vital Signs

  4. The Right Stuff: Fostering An Appropriate and Effective SIU Culture • Visible support from the organization’s highest levels • “Counter-fraud mission woven into the fabric of the organization” • Understanding of the crime, its impact and the plan’s inherent exposure • Appropriate perspectiveon the crime’s incidence and perpetrators and the insurer’s primary mission • Appreciation of the value of—and dedication to—industry-wide counter-fraud cooperation and sharing of case-specific information • Realistic expectations and results-measurement

  5. Theory Made Practice: The Logistics • Formal Counter-Fraud Plan, Policies & Procedures • Clear SIU objectives and strategies for carrying out the core functions • Funding, staffing, tools and resources commensurate with those objectives and strategies • Appropriate placement, staffing and ongoing training • Investigators • Analysts • Clinicians • Committed IT and Legal resources • Effective technology • Effective working relationships—internal and external

  6. The Bottom Line:U.S. Health Insurers’ Anti-Fraud R.O.I. • Average anti-fraud budget: $1.95 mil.* • Average savings & recoveries: $19.1 mil.* • Widespread average PMPY return: $2.50 • Best operations’ PMPY return: $7.50 • Average R.O.I.: 9.6 to 1* • Best operations’ R.O.I. Exceeds 12 to 1 * SOURCE: NHCAA, CY 2011

  7. The Anti-Fraud Vital Signs

  8. The Anti-Fraud Vital Signs

  9. The Anti-Fraud Vital Signs

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