A Perfect 10

There is nothing quite like the smell that hits you as you walk through the doors of a cramped, busy kids’ gymnastics school. It is a mixture of sweat, disinfectant and feet that attacks your olfactory system and causes your body to want to run for fresh air. But, then, you look at the pure joy on your (grand)child’s face as s(he) sees the equipment and their favorite instructor and the smell goes away and is replaced by the contentment, pride and happiness as your progeny walks forward and backward on a 4 inch wide beam while holding a foam block over their head with their arms fully extended.?

In watching that future Olympian, it hits you – balance is the key. To happiness, of course. To success, you bet. To SIU Return on Investment, without a doubt. Wait, what?! What does balance have to do with SIU success? Again, stretching the metaphor to within an? inch of its life, the balance required in gymnastics success is very similar to the balance needed to be successful in health care fraud investigations.?

A successful gymnast dedicates their lives to mastering the techniques – learning the basic skills and practicing them until they are second nature. But to reach the pinnacle, they also must add art to the performance; putting an individual stamp on their performance; creating their own moves within the panoply of required movements. In doing this they hit the balance between mastering the rigid processes and bringing an individual style to the sport (think Simone Biles’ trademark moves).?

Similarly, a good health care fraud SIU has an investigative process in place that checks all the boxes. Leads are generated, the necessary investigative steps are applied and the correct resolutions are reached. The resultant return on investment is good and stable. This is akin to the good gymnast whose routines are technically sound and meet the basic requirements, the technical scores are good but the scores are not optimal because the artistic difficulty scores are low.? As a gymnast can go to the next level by moving beyond technical competency to artistic mastery, so the SIU can go to the next level by balancing process efficiency with individual thought.??

It is essential to any investigation to follow a process. While each case is different, the steps that? are taken need to be conducted in a consistent manner and documented well. That is technical proficiency and will bring results. But to be truly successful, the investigator must move beyond the workflow and bring natural curiosity, deductive reasoning, a desire to solve complex puzzles and attention to detail to every case.??

Process is good but it comes with blinders. A dedication to metrics, contract/compliance requirements and ROI expectations results in a “check-the-box” approach to investigations that can be successful but may miss the big picture. That approach must be balanced with intuition, informed analysis and broader thought so that the bigger picture – patterns, wide spread schemes, emerging trends and program vulnerabilities can be identified, investigated and resolved.?

Environments that can inculcate such a balanced approach include solid workflows, policies and procedures with consistent and inclusive dialogue involving all SIU members (investigators, data analysts and clinical staff and coders) where cases, data projects, trends and insights are discussed and followed up. Staff must be tasked with going beyond “moving cases” to identifying and solving problems and then given the tools and freedom to accomplish those goals.?

It is in establishing and maintaining this balanced approach that can raise the bar. SIU work is both process and art and it is balancing those approaches that will keep the SIU on the beam.?

?By Matt Kochanski