Accurate claim payment can be challenging
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.
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.
Data Mining
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.
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
Learn how to create a framework that drives payment accuracy on the first pass.
Article
Learn how AI is changing the fraud case review process.
Infographic
Learn how a multi-tiered approach to data mining helps maximize savings and achieve payment accuracy earlier in the claim lifecycle.