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Healthcare operations

Claim Review

Prevent improper payments, reduce medical spend and minimize provider abrasion with our comprehensive suite of pre- and post-pay solutions.

Accurate claim payment can be challenging

The dynamic and complicated nature of health care can lead to a high potential for fraud, waste, abuse and error. And many factors magnify this inherent complexity, including:

  • Changing regulations by governing bodies such as the Centers for Medicare & Medicaid Services
  • Confusing and ambiguous payment policies
  • Detailed and customized provider contracts
  • More than 85,000 diagnosis codes
  • Multiple forms of reimbursement

Optum® Claim Review combines pre- and post-payment technology and expert services to maximize savings, reduce repeat errors and minimize provider abrasion.

Drive payment accuracy and maximize savings

We combine advanced claim selection analytics with human expertise to review all claim types across all major reimbursement methodologies.

Leverage advanced analytics

Get best-in-class accuracy with our machine learning models that analyze all claim types and flag the claims most likely to contain errors.

Conduct in-depth human reviews

Experienced coders and clinicians, backed by medical directors, review selected claims against itemized bills and/or medical records.

Continuously improve performance

Insights from reviews help inform and optimize our models to further increase accuracy and savings.

End-to-end claim review

Our comprehensive suite of solutions is available both pre- and post-pay to catch errors at every step in the claim lifecycle. Our services include:

  • Data Mining – Identify claim errors and overpayments related to duplicates, coordination of benefits, billing issues and contract administration. 
  • Professional Claim Review – Identify coding errors, such as upcoding and unbundling, on professional claims by comparing charges against a medical record.
  • Facility Audit – Validate coding and clinical accuracy on inpatient and outpatient facility claims by comparing charges against a medical record.
  • Itemized Bill Review – Identify errors on high-dollar inpatient and outpatient claims with a line-by-line review of the itemized bill. 
  • Hospital Bill Audit – Validate high-dollar inpatient claims against the itemized bill and medical record.
  • Short-Stay Billing Validation – Identify ambulatory or outpatient claims incorrectly billed as inpatient. 

Claim Review Solutions

Optum Data Mining for health plans

Find, recover and prevent claim errors and overpayments related to duplicates, coordination of benefits and billing issues.

Itemized Bill Review

High-dollar inpatient claims are complex and frequently have billing errors. These claims are often paid under percent-of-charge reimbursement contracts. This makes billing errors costly.

Our Itemized Bill Review delivers an incremental $11,000 average savings per inpatient claim.

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Maximize medical spend savings with Optum Claim Review solutions