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Optum, an industry leader in health care payment integrity services, is working with SAS to further enhance its comprehensive health care anti-fraud, waste and abuse services. This enhanced solution combines detection, investigation, prevention, case development and recovery services to provide commercial health plans with a flexible approach to ensuring proper payments to care providers.
While the vast majority of health care spending reflects the actual costs of patient care and medical services, the National Health Care Anti-Fraud Association (NHCAA) estimates that $60 billion is lost annually to health care fraud, waste and abuse. This figure includes such activities as billing for unperformed medical services; performing a medically unnecessary test or procedure; billing for more expensive medical services or procedures than the one conducted; or billing each stage of a procedure in place of a bundled rate.
“Health plans find it challenging to assemble the complex combination of technology and talent required to mount sophisticated anti-fraud defenses,” said Nick Howell, Optum’s senior vice president of operational and administrative efficiency. “By working with SAS, we can further enhance our support of payers seeking to access most sophisticated analytics, the largest datasets, and the largest investigative operations in the industry.”
The Optum solution uses SAS’s Fraud Framework and Optum’s deep health care expertise and extensive health care claims and fraud case datasets to identify and prevent instances of fraud, waste and abuse for payers. The solution delivers broad detection capabilities including rules, flags, predictive modeling, text mining and social network analysis to identify possible instances of provider and consumer fraud, including multi-party fraud schemes and organized crime.
“This solution has a proven track record of detecting improper payments early and stopping them before they negatively impact the health care system,” said Julie Malida, principal for Health Care Fraud Solutions, SAS. “Together, SAS and Optum are uniquely positioned to help the industry address the growing issue of health care fraud, waste and abuse, which shows no signs of abating without intervention.”