Special Investigation Units: Coders Bring Value

Understand what being part of this unique team entails, and if it’s right for you. 

By Lisa Jensen, MHBL, FACMPE, CPC
If you have a passion for medical auditing, you may have obtained, or thought about obtaining, a credential such as Certified Professional Coder (CPC®), Certified Professional Coder-Payer (CPC-P®), Certified Medical Auditor (CPMA®), or other similar AAPC certification. If so, perhaps you should consider working in a special investigations unit (SIU) as a next step in your career.
Before you jump into it feet first, consider the following questions:

  • Do you want to use your skills in a way that can ultimately benefit whole communities?
  • Do you have a keen interest in healthcare compliance and regulatory guidelines?
  • Do you pore over and enjoy coding concepts for many specialties and provider types?
  • Do you have an aptitude for spreadsheets and statistical sampling methodologies?
  • Are you comfortable with medical record auditing and able to abstract charts?
  • Can you competently communicate complex results and make sense of audit findings?
  • Do you want to help medical professionals maximize coding and billing efficiency and the quality of care through auditing?
  • Do you want to find and combat healthcare fraud, waste, and abuse that compromise the health and welfare of healthcare providers and patients?

If you said, “Yes” to all of the above, a career in an SIU might be for you.

Fraud Fighters Are Necessary

The Center for Medicare & Medicaid Services (CMS) Office of the Actuary calculates that the United States spends nearly $3 trillion on healthcare every year—nearly 18 percent of our nation’s gross domestic product. No one knows for sure what percentage of that amount is lost to healthcare fraud, but the National Healthcare Anti-Fraud Association estimates it’s in the tens of billions of dollars each year. This loss directly affects patients, taxpayers, and the government, resulting in higher healthcare costs, insurance premiums, and taxes for everyone.
Financial losses are only part of the story. Sadly, healthcare fraud often harms patients who are exploited and subjected to unnecessary or unsafe medical procedures. Examples from the U.S. Department of Health & Human Services Office of Inspector General include:
A 44-year-old physician in Mason, Ohio, could receive up to 20 years in prison for convincing patients to undergo medically unnecessary spinal surgeries, and billing private and public healthcare benefit programs millions of dollars for fraudulent services.
A 48-year-old physician in Oakland Township, Mich., was arrested and charged in a criminal complaint for his role in a healthcare fraud scheme, which involved submitting false claims to Medicare for medically unnecessary services, including chemotherapy treatments. The doctor billed Medicare for approximately $25 million in inappropriate services, including:

  • Directing the administration of unnecessary chemotherapy to patients in remission;
  • Deliberately misdiagnosing patients as having cancer to justify unnecessary cancer treatment;
  • Administering chemotherapy to end-of-life patients who would not have benefitted from the treatment;
  • Deliberately misdiagnosing patients without cancer to justify expensive testing;
  • Fabricating other diagnoses, such as anemia and fatigue, to justify unnecessary hematology treatments; and
  • Distributing controlled substances to patients without medical necessity and/or administering drugs at dangerous levels.

A 61-year-old physician in Robinson, Ill., was sentenced in federal district court in Benton for obstructing a criminal healthcare fraud investigator by giving an auditor a patient progress note that was altered to show an in-office examination previously claimed that had not taken place. The doctor billed claims for in-person office visits for which the patient either failed to show up for an appointment, or only was spoken to by telephone. The physician was sentenced to serve three years of probation, 30 days in prison, a fine of $10,000, a special assessment of $100, and was ordered to pay restitution to BlueCross BlueShield of Illinois in the amount of $19,615.17. In a civil settlement, the doctor also was ordered to pay double damages of $87,348.64.
Patients and healthcare providers also may be the victims of identity theft. For providers, it often results in damage to their professional reputations.

Know How SIUs Work

SIUs use a variety of strategies to fight fraud, including:

  • Prosecution focused (e.g., staffed by former law enforcement, coders, and nurses with the goal of prosecution);
  • Team oriented, with professionals such as nurses, doctors, coders, and analysts arranged around a particular specialty, geographical location, or skill set; or
  • Financially focused, with auditors, investigators, professional coders, nurses, and doctors working to identify and recover financial harm.

Most SIUs use sophisticated software designed to analyze large amounts of claims data, to identify outliers, and to focus SIU efforts on recovering previously paid claims. Some data analytics are used to predict inappropriate billing behavior and prevent fraudulent, abusive, or wasteful payments. Most SIUs are designed to work collaboratively within their organization to comply with healthcare compliance regulations and the growing list of legislative requirements.
Organizations having an SIU can range from government agencies to health insurance companies and other healthcare organizations. An SIU can increase an organization’s competitive advantage by demonstrating an active commitment to integrity and compliance, while satisfying the need to control costs and remain fairly priced in the market.

Bring Your Expertise to an SIU Team

As a coder, you’re incredibly valuable to an SIU team. They are asked to look for patterns or trends of suspicious coding behaviors, such as:

  • A high percentage of highest-level evaluation and management (E/M) coding
  • The application of modifiers, such as modifier 25 Significant, separately identifiable evaluation and management services by the same physician on the same day of the procedure or other service and modifier 59 Distinct procedural service, to the majority of services
  • A high number of re-billings with claim modifications

As a professional coder, you have the knowledge and coding skills necessary to translate complex billing rules to law enforcement and others who lack medical coding familiarity. You can determine when a provider has billed for one service and documented another: This information—added to nurse’s or doctor’s determination of medical necessity—can ensure a poor performing provider is either corrected or deterred from further inappropriate billing.
You also become a valuable resource to the federal government, insurance company, or healthcare organization by bringing coding resource knowledge and research skills to company-wide needs. For example, you can help provide coding and compliance education programs; find ways to improve claims processing to reduce overall vulnerability to fraud, waste, and abuse; and ensure correct and timely payment to the vast majority of reputable providers.
The typical SIU workflow is:

  1. You receive a tip or referral either through data or a complaint.
  2. You assess the concern for validity, and investigate using documentation such as chart notes, receipts, enrollment forms, or interviews.
  3. You gather all facts, make recommendations, and see them through to final resolution.

Findings are very often either a non-issue or simply an education need; however, there are other resolutions, such as referrals to law enforcement, CMS, and/or recovery of funds.

Set Your Sights for an SIU Career

If a career in SIU interests you, scan want ads and online postings for terms such as “healthcare fraud investigator,” “Medicare fraud investigator,” or “fraud auditor.” This will give you an idea of the skills and experience health insurance companies, consultants, vendors, and federal and state employers are looking for. Most employers request a bachelor’s degree in a field related to fraud, such as accounting, auditing, criminal justice, criminology, or pre-law. They may prefer former law enforcement professionals, and most require experience with Medicare/Medicaid laws, rules, and regulations.
Employers may expect two to five years experience in an investigation, audit, and/or fraud-related field, and you’ll need basic fraud investigation experience before you’ll be hired as a healthcare fraud investigator. This can include working:

  • In a healthcare organization’s compliance department;
  • As an accountant who works with fraud detection;
  • As an insurance claim adjuster or criminologist in white-collar-crime detection; or
  • In another investigative/auditing role that is directly relevant to the SIU position you desire.

Most employers also prefer relevant certification. In addition to AAPC certifications, employers are looking for fraud-specific certifications such as Certified Fraud Examiner (CFE) and Accredited Health Care Fraud Investigator (AHFI®). Certification programs prepare you for the unique fraud investigation role, and carry the respect employers are looking for. To attain these, become a member of organizations such as the Association of Certified Fraud Examiners or the National Health Care Anti-Fraud Association. You’ll have to meet educational requirements, complete an application, provide proof of work experience, reference letters, and pass an exam. When you’ve attained additional certification, update your resume to highlight relevant work experience, training, and certifications.
If you read AAPC Cutting Edge, you are likely one of the thousands of healthcare professionals committed to upholding a higher standard, remaining diligent, and always improving yourself. Even though most providers are reputable, there is no shortage of those who put personal financial gain over patient safety and the financial welfare of our nation. Lending your skills, expertise, and passion for correct coding to the area of SIUs may be the most valuable use of your talents and a very rewarding experience.

Lisa Jensen, MHBL, FACMPE, CPC, is manager of the Special Investigations Unit at Providence Health Plans in Beaverton, Ore. She has a master’s degree in Healthcare Business Leadership and has been a CPC® since 1996. Jensen is a member of the Medical Group Managers Association and has attained fellowship status in the American College of Medical Practice Executives in 2008. She has spent much of her 23 years in healthcare gaining a broad range of experiences in small physician’s clinics, multi-practice medical/surgical practices, a large teaching hospital, compliance consulting, and a medium-size health plan. Jensen is a member of AAPC’s Portland Columbia River, Ore., local chapter.
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Renee Dustman, BS, AAPC MACRA Proficient, is managing editor - content & editorial at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 30 years' experience in journalistic reporting, print production, graphic design, and content management. Follow her on Twitter @dustman_aapc.

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