“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.