Prospective Fraud, Waste and Abuse Investigation Overview

Augment traditional recovery efforts

We process more than 200 million claims representing more than 1.4 million providers and put this intelligence to use to help your organization achieve significantly greater customer savings than when using recovery efforts alone. Thorough pre-payment investigation drives more effective business results for you without disrupting your overall claims process or jeopardizing your compliance with prompt pay regulations.

Prospective detection

• Apply proprietary detection technology developed from real-world investigation experience
• Augment your existing anti-fraud initiatives by identifying providers who demonstrate aberrant billing trends and patterns
• Identify aberrant billing practices and possible fraud and abuse by mining the data to reveal hidden patterns and relationships

Investigation claim review

Once the review process has been completed, each flagged claim is reviewed and investigated by a team of experienced clinical and investigative personnel—prior to payment. Upon completion of this focused investigative review, we provide you with information to determine whether the claim should be paid or denied. In doing so, we can help save up to half of every dollar investigated and remain compliant with state prompt pay requirements.

The cost of managing fraud and abuse

Industry estimates indicate that two to seven percent of health expenditure dollars are lost to fraud and abuse. The expertise needed to perform proper investigation and recovery efforts is considerable, the costs incurred are significant, and there is no guarantee any recovery amounts will actually materialize. Let OptumInsight experts help you detect fraud and abuse claims before claims are paid.