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Special Investigations Unit

Ret: $ amount cost avoidance generated by the Special Investigations Unit

Current Value

$630,289

SFQ3 2023

Definition

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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.

Story Behind the Curve

This measure is important because the Special Investigations Unit (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 members that are no longer eligible for benefits. 

The SIU seeks to interact with providers through proactive provider audits, educational outreach opportunities, and case referrals.  The SIU strives to educate providers as appropriate, recover funds when necessary, and avoid wasting Medicaid funds.  One of the SIU approaches to prevent the fraud, waste, and abuse of Medicaid funds is to avoid the cost entirely.  In essence, when you cost-avoid unnecessary or inappropriate funds from being paid out, the program is preventing waste and abuse, which minimizes pay and chase.  Cost avoidance is estimated from point of contact with the provider and the estimated savings from a changed billing pattern.  The performance data compiled to date indicates the more providers SIU contacts, the more cost avoidance is realized.  The SIU also records cost avoidance when we are involved in the removal of members from Vermont Medicaid that are no longer eligible for benefits.  When members are no longer residents of Vermont and reside in another state, their benefits in Vermont would be terminated. 

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

Narrative last updated:  02/07/23

Partners

  • Clinical Operations Unit
  • Member Provider Services Unit
  • Health Access, Enrollment and Eligibility Unit
  • Medicaid Providers
  • Gainwell Technologie

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Scorecard Container Measure Action Actual Value Target Value Tag S A m/d/yy m/d/yyyy