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.”
“Health care payers that adopt an enterprise approach to fraud prevention help their organizations realize immediate operational cost recovery, and enable greater savings over time,” said Christina Lucero, principal research analyst for commercial health plans at Gartner, Inc. “Partnerships that integrate both health care experience and new technologies provide the greatest opportunity for change in the way we traditionally address fraud and abuse, enabling focus on prevention vs. pay-and-chase methods.”Specific benefits of this solution include:
- Reduced investment: The solution does not require users to purchase, install or maintain software. This means a reduced investment for health plans in terms of both time and capital – and extends the capabilities to mid- and smaller-sized plans.
- Improved detection speed and accuracy: The solution applies a broad range of analytics, both prospectively (pre-pay) and retrospectively (post-pay), to scan more than 1 million claims per day to improve detection efforts and find fraud quickly and accurately. These advanced, proprietary analytics include anomaly detection, predictive modeling, social network analysis, text mining and rules to filter out fraudulent, wasteful and abusive transactions.
- Integrated detection, investigation, case development and recovery services: The framework provides access to Optum’s extensive clinical, investigative and recovery resources, including more than 600 anti-fraud, waste and abuse professionals. Optum’s multi-disciplinary staff combines medical experts, certified professional coders, statisticians and special investigative unit professionals.