Like most SIUs, MVP Health Care’s SIU was faced with an overloaded team that was fielding requests from across the organization. Their goal was to be as responsive as possible to all requests coming into the department but had a desire to shift a portion of their focus to the most egregious providers or the highest dollar issues.
They looked to AI-driven provider education as a way for their SIU to focus on both broad reach waste, and high dollar top offenders.
During the recent Codoxo Xcelerate Conference, Rocco Cordato, Director of the Special Investigations Unit and Payment Integrity at MVP Health Care, shared his organization’s journey to adopting Codoxo’s Provider Scope and provider portal within their SIU to identify providers in need of education and deliver the education to those providers to help improve compliance and set the foundation for future SIU efforts.
Addressing High-Volume, Low-Dollar Challenges
Rocco explained that MVP Health Care’s SIU team was often inundated with high-volume, low-dollar coding and billing issues that consumed significant resources without commensurate returns. To tackle this challenge, the team recognized the need for a more proactive and scalable approach to provider education.
Implementing an AI-Driven Program
To address this, MVP Health Care partnered with Codoxo to implement a provider education program using Codoxo’s Provider Scope solution. Rocco highlighted the key steps in their process:
- Gaining alignment on value with an internal committee to evaluate cost savings opportunities and current spend while securing additional resources.
- Validating opportunity through a pilot program that proved value.
- Securing buy-in from internal stakeholders, such as the provider relations and network teams, to ensure alignment on the program’s objectives and communication strategies.
- Carefully vetting the provider population to exclude those with active SIU cases or under value-based payment arrangements in order to isolate the impact of the education efforts.
- Establishing a quarterly cadence for the program, including letter campaigns, portal access, and ongoing communication with providers.
Learned Best Practices
- Working with a current vendor streamlined data processes – MVP was an existing Codoxo Fraud Scope customer with an established data stream which made the transition to provider education more streamlined.
- Assess provider payment arrangements – particularly if you are using value-based payments to ensure you can look at unit by unit.
- Be prepared to conduct provider data cleanup and validation – to ensure accurate and complete specialties, addresses, phone numbers, etc.
Achieving Tangible Results
Rocco emphasized the “sentinel effect” where the mere presence of the education program has influenced provider behavior, even without direct engagement. Additionally, the team has been able to build a historical record of provider interactions, which can be leveraged in future SIU investigations.
Codoxo’s Provider Scope solution also provided MVP Healthcare with several key benefits:
- Cross-visibility between the SIU and provider education teams, allowing them to track provider interactions and build a chain of evidence for future investigations.
- Automated outreach and follow-up processes, including letters, portal access, and outbound calls to drive provider engagement.
- Access to a team of certified coders who can provide guidance and support to providers on their specific billing and coding questions.
The Power of Collaboration and a Long-Term Perspective
Rocco stressed the importance of patience and a long-term perspective when implementing such programs, as changing provider behavior takes time and consistent effort. He also highlighted the value of cross-collaboration between the SIU, Payment Integrity, and other key stakeholders to ensure the program’s success.
Expanding the Scope
Looking ahead, MVP Health Care plans to expand the program into additional areas, such as referring providers, home health, and lab services, where AI-driven education can drive meaningful impact. Rocco noted that these less concrete areas present opportunities to further enhance their provider education efforts.
A Call to Action
The session underscored the transformative potential of AI-powered provider education programs. Healthcare organizations are encouraged to explore Codoxo’s solutions as a means of enhancing their own provider education initiatives and driving sustainable improvements in coding and billing compliance.
To learn more about Codoxo’s Provider Scope, contact us at info@codoxo.com or visit https://info.codoxo.com/xceleratedemo