Research and track investigations of fraud, waste and abuse
Optum Program Integrity™ analyzes data to detect suspicious activity for both providers and members. It pursues aberrant behaviors with a minimal rate of false positives. And it tracks the progress from preliminary to full-scale investigations, through appeals and recoupments.
This solution helps states meet CMS standards that allows them to access federal matching funds for their operations.
Manage investigations from detection to collection
Discovery and detection
We offer focused analytics, long-term care review, peer-group profiling, predictive scoring and detection of spikes in provider activity.
Support and materials
Get support in developing new analytics and models. Access online user manuals and training guides. Stay informed with weekly strategy calls with investigators and yearly users’ meetings.
Research
Our analytical library, inquiry capabilities, guided machine learning and reference reports provide deep insights.
Case management
Manage cases with aging and summary reports, inquiry capabilities, and integrated case tracking. Complete investigator tracking, notes, attachments, findings and more.
Key benefits
Here are ways we help states address fraud, waste and abuse.
Conduct investigations and audits
Easily track investigations from recognition to final disposition.
Perform reviews
Verify findings with a long-term care review.
Recover improper payments
Help prevent improper payments and flag likely overpayment.
Educate stakeholders
Assist with educating stakeholders against abusive billing practices.
Collaborate with government bodies
Collaborate with the Medicaid Fraud Control Division (MFCD) and other state and federal bodies.
Real results
An analysis and audit by the Arkansas Office of Medicaid Inspector General using Program Integrity helped identify Ambulance Life Support (ALS) as a top area where the agency needed to educate providers against abusive billing practices. In the year following the analysis, audit, education effort, and outreach to top outliers, there was:
- $1.79 million saved in total dollars paid to transportation provider groups
- 16.4% program-wide reduction in ALS claims
Prevent improper payments and identify gaps and trends
Reduce costs with a solution that prevents improper payments, supports provider education and interfaces with treatment groupings. Certified by CMS in 11 states.
Easily track investigations from recognition to final disposition.
Pinpoint high-risk billing patterns with predictive lead scoring, which points to claims with a high probability of overpayment.
Uncover abnormal behaviors with statistical analysis in peer groups you define.
Intra-claim and cross-claim analysis detects hidden, collusive and more complicated fraud schemes.
Configure to align with your state’s system.
Related healthcare insights
White paper
By applying analytics solutions, states can create a comprehensive roadmap to better health equity.
Case study
Optum has completed more than 200K+ assessments in Arkansas, helping coordinate care for people with chronic, high-cost and long-term care needs.
Case study
See how Optum helped one state visualize utilization and demographic data around behavioral health programs.