Special Investigations Unit

$ amount cost avoidance generated by the Special Investigations Unit

$681,371SFQ4 2022

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Notes on Methodology
  • Please note while there is no specific target for this measure, the goal is to increase avoidance amount over time by increasing the number of providers we are in contact with and the removal of beneficiaries that are no longer eligible for benefits.

Partners
  • Policy Unit
  • Clinical Operations Unit
  • Provider Member Relations Unit
  • Medicaid Providers
  • Gainwell Technologies
Story Behind the Curve

This measure is important because SIU strives to increase the quarterly cost avoidance amount over time by increasing the number of providers we are in contact with and the removal of beneficiaries that are no longer eligible for benefits. 

The SIU seeks to interact with providers through proactive provider audits, educational outreach opportunities, and through case referrals.  SIU strives to educate providers as appropriate, recover funds when necessary, and successfully and cost-avoid wasted Medicaid funds.  One of the SIU approaches to prevent the fraud, waste and abuse of Medicaid funds, is to avoid the cost entirely through cost-avoidance.  In essence, when you cost-avoid unnecessary or inappropriate funds from being paid out, the program is preventing waste and abuse.   The performance data compiled to date indicates the more providers SIU contacts, the more cost avoidance is realized.  SIU also records cost avoidance when we are involved in the removal of beneficiaries from Vermont Medicaid that are no longer eligible for benefits. 

The chart depicts the quarterly impact of our cost avoidance measured to date for both our provider and beneficiary cost avoidance.  COVID had an impact on this measure by delaying the removal of beneficiaries from Medicaid and reducing the providers outreached during that time.

Narrative last updated:  04/21/2022

Scorecard Result Container Indicator Measure Action Actual Value Target Value Tag S R I P PM A m/d/yy m/d/yyyy