Optum partners closely with states, working collaboratively to provide focused analytics on a quarterly basis. States are empowered to proactively monitor and safeguard their Medicaid programs, ensuring beneficiaries receive quality services while supporting efforts to detect and prevent fraud, waste and abuse. The partnership fosters transparency, trust and shared success in meeting each state’s unique needs.
“We share our findings with states, and then those agencies decide how to proceed with the information,” explains Ulyana Peychev, senior manager, Business System Analysis at Optum. “They could potentially refer it to Medicaid Fraud Control Units, submit a Credible Allegation of Fraud Case, send a referral for an internal investigation or request more information.”
The research also provided important information for other states about the vendor's operations in their areas. The vendor’s parent company was sued in 2023 for breaching the personally identifiable information and protected health information of 1.2 million individuals who used the vendor's services.
Due to the data breach, the parent company is no longer providing services in some states.
Analytics give states greater power to detect fraud, waste and abuse.
“An algorithm compares millions of claims and quickly identifies the outliers,” explains Peychev. “If you were doing this work manually, you might not always catch the improper payment. And that’s because the algorithm captures all of the data from the entire electronic data warehouse, going far beyond the few claims that you may have on your desk.”
