Fraud and abuse detection

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NARRATOR: Across health care, fraud schemes move fast, exploiting gaps, shifting tactics, and outpacing traditional controls. By the time fraud is detected, it's often too late. Optum is changing that. We're moving fraud detection upstream, stopping suspicious activity before claims are paid. What makes this possible is our unique vantage point.

We can see across payers, across providers, across the healthcare system. Our suite of products connects data at scale and applies advanced analytics, AI, and decades of experience fighting fraud to reveal patterns that may not be visible to an individual payer acting on their own. Together, they assess provider risk, surface emerging threats, and enable decisive action.

Every year, tens of thousands of new providers enter the system. Many are legitimate. Some are not. Our enhanced provider verification technology technology evaluates provider integrity and risk the moment they attempt to enroll. We instantly map each provider into a network of identities, relationships, and historical behavior, enabling payers to verify whether the provider exists and whether they should be trusted.

If risk is detected, claims are held and an investigation begins, stopping hit-and-run fraud before a single dollar leaves the system. And because

provider status can change, we proactively reassess integrity after enrollment, monitoring for changes to the risk a provider poses. Our advanced AI models continuously analyze provider behavior, uncover hidden connections across vast data sets, and identify anomalies which may signal emerging schemes.

Investigative tools map how entities and transactions interlink, making even sophisticated schemes visible. When suspicious patterns appear,immediate alerts are triggered, empowering payers to act before losses mount. Optum is making this possible, innovating at the speed and scale modern health care demands.

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