Helping health plans improve payment accuracy
The dynamic and complicated nature of healthcare 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
Comprehensive claim review
Optum® Claim Review combines pre- and post-payment technology and expert services to maximize savings, reduce repeat errors and minimize provider abrasion.
Validate coding and payment accuracy
Powered by the most advanced payment accuracy engine, we combine AI and human expertise to review claims across reimbursement methodologies.
AI-augmented claim selection
Our integrated analytic suite leverages AI to fine-tune claim selection, facilitating improved accuracy and reduced provider abrasion.
Expert coding reviews
We use AI to support our auditors with context-aware insights which improve quality and empower our experts to focus on decision-making.
Real-time learning
Insights from reviews help inform our models to further increase accuracy.
End-to-end claim review
Our market-leading pre- and post-payment solutions catch errors and improve accuracy at every step in the claim lifecycle.
Service
Professional Claim Review
Identify coding errors, such as upcoding and unbundling, on professional claims by comparing charges against a medical record.
Software
Facility Claim Review
Validate coding and clinical accuracy on inpatient and outpatient facility claims by comparing charges against a medical record.
Service
Itemized Bill Review
Identify errors on high-dollar inpatient and outpatient claims with a line-by-line review of the itemized bill.
Service
Hospital Bill Audit
Validate high-dollar inpatient claims against the itemized bill and medical record.
Service
Short-Stay Billing Validation
Identify ambulatory or outpatient claims incorrectly billed as inpatient.
Service
Data Mining
Identify claim errors and overpayments related to duplicates, coordination of benefits, billing issues and contract administration.
Drive more results from your claim review program
Our pre- and post-pay Claim Review solutions combine advanced technology and human expertise to prevent improper payments, reduce medical spend and minimize provider abrasion. Our results:
- 100% of claims are risk-scored daily
- True positive rates can approach 70% or more
- Less than 2% of appeals are overturned
- 2-5% of medical expenses can be saved with an integrated pre- and post-pay solution
Related healthcare insights
E-book
This guide can help you optimize your payment integrity program and achieve savings goals within 12 months.
E-book
Learn about a modern and proactive approach to payment integrity for health plans.
White paper
Unpack key trends shaping the future of payment integrity and discover steps you can take to get started on your path to payment precision.