Predict. Prevent. Protect.
Transform.
Program Integrity Solutions for Medicaid
Medicaid Fraud Control Unit Analytics Support
We offer a comprehensive suite of Medicaid-proven tools, services and expert staff support to help Medicaid Fraud Control Units accurately identify instances of fraud and neglect, as well as increase the speed of case development, pursuit and prosecution.
Social Networking/Linkage Analysis
We provide Medicaid-specifi c fraud models that detect broad social networks, allow review of fi ndings and support case development and litigation based on historical claims data.
Subrogation
Optum analyzes paid claims data to determine the potential for accident-injury related cases in which insurance other than Medicaid would apply.
Estate Recovery
Our subject matter experts conduct comprehensive analysis of a variety of data sources to assist states in recovering expenses according to state statutes.
Based on more than 30 years of experience,
Optum Program IntegritySolutions are an integrated set of analytic solutions — presented in a web environment and backed by experienced staff — to deliver actionable intelligence. The information generated enables governments to prevent erroneous payments, research inappropriate payments, confi dently pursue suspicious activity, compile and access accurate information and increase recoveries.
Government expertise
A national leader in providing recovery services for Medicaid programs, Optum has worked with more than 30 government programs and with every major Medicaid fi scal agent service provider, saving states millions every year.
To learn more about how Optum can help improve your state’s program integrity programs:
Call: 1-800-765-6092
Email: [email protected]
Visit: optum.com
Evaluation
Program and Operational Assessments, Systems Analysis and Vulnerability
Assessments, Policy Review, Program Management
Our program integrity experts assist states in improving the performance of their program integrity efforts and operations. We provide full program assessments and strategic guidance on the overall program, processes, system vulnerabilities and policies as well as recommendations for remediation. We also help to prioritize improvements to meet state objectives and regulations.
Pre-payment solutions
Electronic Visit Verifi cation
Optum Electronic Visit Verifi cation solution uses global positioning system technology for verifi cation of mobile assets, providing a platform for measuring, recording and verifying home and community-based caregiver and transportation services in real time.
Predictive Analytics
Our pre-payment fraud detection solution uses advanced predictive analytics services to measure improper payment risk and identify anomalies in providers’ claims to uncover inaccuracies before the claim is paid, with no disruption to the payment cycle.
Social Networking/Linkage Analysis
We provide Medicaid-specifi c fraud models that detect broad social networks, allow review of fi ndings and support case development and litigation before payment is made.
Claims Editing System
Optum Claims Editing System (CES) is an open-architecture claims editing tool that complements any existing claims adjudication platform to automatically review and edit claims submitted by providers and facilities.
Injury Coverage Coordination
Have confi dence that accident claims are paid by the appropriate parties. Motor vehicle accidents, medical negligence, work-related accidents, premises liability and defective product injury cases are among those investigated to determine liability responsibility.
Post-payment solutions
Retrospective Review and Recovery
With our post-payment approach, our sophisticated fraud detection technology and predictive analytics examine historical claims to identify patterns and trends that signify fraudulent or abusive activity for review by government staff.
Fraud and Abuse Detection System
Optum Fraud and Abuse Detection System (FADS) is a web-based platform that mines claim, provider and client data to identify irregularities in data often indicative of fraud, abuse, error and waste. When all components are installed, FADS helps states meet all of the Centers for Medicare and Medicaid Services Program Integrity Checklist requirements.
Credit Balance Services
Optum provides onsite credit balance auditors to augment existing efforts of both Medicaid and its providers to communicate, resolve and recover claims overpayments.
Our proven recovery solutions give states comprehensive options for detecting and recovering inappropriate payments — all from one trusted and proven partner, Optum. The comprehensive Program Integrity suite from Optum includes expertise, methodologies and tools to optimize your operations and improve performance.
Prevent inappropriate payments from being made through pre-payment solutions — a more effi cient way to contain costs, particularly when coupled with traditional post-pay and recovery activities.
optum.com 13625 Technology Drive, Eden Prairie, MN 55344
All Optum trademarks and logos are owned by Optum. All other brand or product names are trademarks or registered marks of their respective owners. Because we are continuously improving our products and services, Optum reserves the right to change specifi cations without prior notice. Optum is an equal opportunity employer.
Fraud, waste and abuse: a continuing challenge
The integrity of Medicaid programs is a key priority for all program personnel. Every day, they demonstrate their dedication by revealing billing errors and correcting fraud, waste and abuse. Payment accuracy is the goal, as is a positive return on all technological investments to improve overall program integrity.
Detecting fraud, waste and abuse is complex; it can run the gamut from simple coding errors or billing for unnecessary procedures to organized crime networks. To truly address the problem of fraud, waste and abuse, Medicaid program integrity processes need to evolve to detect the ever-changing face of fraud.
Optum
TMProgram Integrity Solutions are helping to transform
program integrity into a more proactive, nimble process.
Up until very recently, most states have focused on retrospective recovery. Today, states are in a position to reinvent the program integrity process, by moving the identifi cation of a potential problem to the front-end of the claims cycle before payment is made.
Optum Program Integrity Solutions are an integrated set of analytic solutions — presented in a web environment and backed by experienced staff — to deliver actionable intelligence. The information generated enables governments to prevent erroneous payments, research inappropriate payments, confi dently pursue suspicious activity, compile and access accurate information and increase recoveries. Optum provides:
• Advanced detection analytics designed exclusively for Medicaid
• Deep expertise in designing and using government payment and analytic systems • Low-risk, well-established processes and solutions with proven results
• Comprehensive and fl exible approaches: from services and software to business process outsourcing
Results
Optum Program Integrity Solutions helped 22 clients realize more than $300 million savings in 2012 alone.
Program Integrity Solutions
Optum provides 30 years’ worth of government expertise and a full range of program integrity solutions to identify and avoid incorrect payment upfront, as well as retrospectively recover inaccurate, inappropriate or fraudulent Medicaid payments.
Optum currently works with 22 government clients, saving states millions every year.
Proprietary and Confidential. Do not distribute.
Optum Program Integrity
California Nevada
Utah
Colorado Arizona
New Mexico Alaska
Texas Oklahoma Kansas Nebraska South Dakota Wyoming
Idaho
Montana
North Dakota Minnesota
Iowa Missouri Arkansas
Wisconsin Michigan Illinois Indiana Ohio
Kentucky Tennessee Louisiana
Mississippi
Alabama Georgia South Carolina Florida North Carolina
Virginia West Virginia –
Credit Balance
Pennsylvania New York
Maine Washington
Oregon
MA VT
Hawaii
NH CT MD
DE
NJ
Washington, D.C.
RI
Optum Program Integrity Clients
Predictive
Analytics
Claims Editing System
(facility and professional)
Optum Program Integrity Solutions
Pre-payment
Post-payment
Injury Coverage
Coordination
Retrospective Review
and Recovery
Fraud and Abuse
Detection System
Credit Balance
Services
Medicaid Fraud
Control Unit
Analytics Support
Social Networking/
Linkage Analysis
Subrogation
Estate Recovery
Evaluation
Program and Operational Assessments • Systems Analysis and Vulnerability Assessments • Policy Review • Program Management
Electronic Visit
Verifi cation
Social Networking/
Linkage Analysis
Medicaid-Tuned
Analytics
Medicaid-Tuned
Medicaid-Tuned
Medicaid-Tuned
Analytics
Medicaid-Tuned
Analytics
Medicaid-Tuned
Analytics
Medicaid-Tuned
Analytics
Analytics
Medicaid-Tuned
Analytics
Analytics
Predict. Prevent. Protect.
Transform.
Program Integrity Solutions for Medicaid
Medicaid Fraud Control Unit Analytics Support
We offer a comprehensive suite of Medicaid-proven tools, services and expert staff support to help Medicaid Fraud Control Units accurately identify instances of fraud and neglect, as well as increase the speed of case development, pursuit and prosecution.
Social Networking/Linkage Analysis
We provide Medicaid-specifi c fraud models that detect broad social networks, allow review of fi ndings and support case development and litigation based on historical claims data.
Subrogation
Optum analyzes paid claims data to determine the potential for accident-injury related cases in which insurance other than Medicaid would apply.
Estate Recovery
Our subject matter experts conduct comprehensive analysis of a variety of data sources to assist states in recovering expenses according to state statutes.
Based on more than 30 years of experience,
Optum Program IntegritySolutions are an integrated set of analytic solutions — presented in a web environment and backed by experienced staff — to deliver actionable intelligence. The information generated enables governments to prevent erroneous payments, research inappropriate payments, confi dently pursue suspicious activity, compile and access accurate information and increase recoveries.
Government expertise
A national leader in providing recovery services for Medicaid programs, Optum has worked with more than 30 government programs and with every major Medicaid fi scal agent service provider, saving states millions every year.
To learn more about how Optum can help improve your state’s program integrity programs:
Call: 1-800-765-6092
Email: [email protected]
Visit: optum.com
Evaluation
Program and Operational Assessments, Systems Analysis and Vulnerability
Assessments, Policy Review, Program Management
Our program integrity experts assist states in improving the performance of their program integrity efforts and operations. We provide full program assessments and strategic guidance on the overall program, processes, system vulnerabilities and policies as well as recommendations for remediation. We also help to prioritize improvements to meet state objectives and regulations.
Pre-payment solutions
Electronic Visit Verifi cation
Optum Electronic Visit Verifi cation solution uses global positioning system technology for verifi cation of mobile assets, providing a platform for measuring, recording and verifying home and community-based caregiver and transportation services in real time.
Predictive Analytics
Our pre-payment fraud detection solution uses advanced predictive analytics services to measure improper payment risk and identify anomalies in providers’ claims to uncover inaccuracies before the claim is paid, with no disruption to the payment cycle.
Social Networking/Linkage Analysis
We provide Medicaid-specifi c fraud models that detect broad social networks, allow review of fi ndings and support case development and litigation before payment is made.
Claims Editing System
Optum Claims Editing System (CES) is an open-architecture claims editing tool that complements any existing claims adjudication platform to automatically review and edit claims submitted by providers and facilities.
Injury Coverage Coordination
Have confi dence that accident claims are paid by the appropriate parties. Motor vehicle accidents, medical negligence, work-related accidents, premises liability and defective product injury cases are among those investigated to determine liability responsibility.
Post-payment solutions
Retrospective Review and Recovery
With our post-payment approach, our sophisticated fraud detection technology and predictive analytics examine historical claims to identify patterns and trends that signify fraudulent or abusive activity for review by government staff.
Fraud and Abuse Detection System
Optum Fraud and Abuse Detection System (FADS) is a web-based platform that mines claim, provider and client data to identify irregularities in data often indicative of fraud, abuse, error and waste. When all components are installed, FADS helps states meet all of the Centers for Medicare and Medicaid Services Program Integrity Checklist requirements.
Credit Balance Services
Optum provides onsite credit balance auditors to augment existing efforts of both Medicaid and its providers to communicate, resolve and recover claims overpayments.
Our proven recovery solutions give states comprehensive options for detecting and recovering inappropriate payments — all from one trusted and proven partner, Optum. The comprehensive Program Integrity suite from Optum includes expertise, methodologies and tools to optimize your operations and improve performance.
Prevent inappropriate payments from being made through pre-payment solutions — a more effi cient way to contain costs, particularly when coupled with traditional post-pay and recovery activities.
optum.com 13625 Technology Drive, Eden Prairie, MN 55344
All Optum trademarks and logos are owned by Optum. All other brand or product names are trademarks or registered marks of their respective owners. Because we are continuously improving our products and services, Optum reserves the right to change specifi cations without prior notice. Optum is an equal opportunity employer.
Optum Program Integrity Solutions
Pre-payment
Post-payment
Pre-payment
Post-payment
Post-payment
Post-payment
Post-payment
Post-payment
Pre-payment
Pre-payment
Predictive
Analytics Retrospective Review and Recovery
Fraud and Abuse Detection System
Credit Balance Services
Medicaid Fraud Control Unit Analytics Support Social Networking/
Linkage Analysis
Subrogation Estate Recovery
Electronic Visit Verifi cation
Medicaid-Tuned Tuned Tuned Tuned Tuned Tuned Tuned Tuned Tuned Analytics Analytics Analytics Analytics Analytics
Evaluation
Program and Operational Assessments • Systems Analysis and Vulnerability Assessments • Policy Review • Program Management
Social Networking/ Linkage Analysis
Claims Editing System (facility and professional)
Injury Coverage Coordination
Predict. Prevent. Protect.
Transform.
Program Integrity Solutions for Medicaid
Medicaid Fraud Control Unit Analytics Support
We offer a comprehensive suite of Medicaid-proven tools, services and expert staff support to help Medicaid Fraud Control Units accurately identify instances of fraud and neglect, as well as increase the speed of case development, pursuit and prosecution.
Social Networking/Linkage Analysis
We provide Medicaid-specifi c fraud models that detect broad social networks, allow review of fi ndings and support case development and litigation based on historical claims data.
Subrogation
Optum analyzes paid claims data to determine the potential for accident-injury related cases in which insurance other than Medicaid would apply.
Estate Recovery
Our subject matter experts conduct comprehensive analysis of a variety of data sources to assist states in recovering expenses according to state statutes.
Based on more than 30 years of experience,
Optum Program IntegritySolutions are an integrated set of analytic solutions — presented in a web environment and backed by experienced staff — to deliver actionable intelligence. The information generated enables governments to prevent erroneous payments, research inappropriate payments, confi dently pursue suspicious activity, compile and access accurate information and increase recoveries.
Government expertise
A national leader in providing recovery services for Medicaid programs, Optum has worked with more than 30 government programs and with every major Medicaid fi scal agent service provider, saving states millions every year.
To learn more about how Optum can help improve your state’s program integrity programs:
Call: 1-800-765-6092
Email: [email protected]
Visit: optum.com
Evaluation
Program and Operational Assessments, Systems Analysis and Vulnerability
Assessments, Policy Review, Program Management
Our program integrity experts assist states in improving the performance of their program integrity efforts and operations. We provide full program assessments and strategic guidance on the overall program, processes, system vulnerabilities and policies as well as recommendations for remediation. We also help to prioritize improvements to meet state objectives and regulations.
Pre-payment solutions
Electronic Visit Verifi cation
Optum Electronic Visit Verifi cation solution uses global positioning system technology for verifi cation of mobile assets, providing a platform for measuring, recording and verifying home and community-based caregiver and transportation services in real time.
Predictive Analytics
Our pre-payment fraud detection solution uses advanced predictive analytics services to measure improper payment risk and identify anomalies in providers’ claims to uncover inaccuracies before the claim is paid, with no disruption to the payment cycle.
Social Networking/Linkage Analysis
We provide Medicaid-specifi c fraud models that detect broad social networks, allow review of fi ndings and support case development and litigation before payment is made.
Claims Editing System
Optum Claims Editing System (CES) is an open-architecture claims editing tool that complements any existing claims adjudication platform to automatically review and edit claims submitted by providers and facilities.
Injury Coverage Coordination
Have confi dence that accident claims are paid by the appropriate parties. Motor vehicle accidents, medical negligence, work-related accidents, premises liability and defective product injury cases are among those investigated to determine liability responsibility.
Post-payment solutions
Retrospective Review and Recovery
With our post-payment approach, our sophisticated fraud detection technology and predictive analytics examine historical claims to identify patterns and trends that signify fraudulent or abusive activity for review by government staff.
Fraud and Abuse Detection System
Optum Fraud and Abuse Detection System (FADS) is a web-based platform that mines claim, provider and client data to identify irregularities in data often indicative of fraud, abuse, error and waste. When all components are installed, FADS helps states meet all of the Centers for Medicare and Medicaid Services Program Integrity Checklist requirements.
Credit Balance Services
Optum provides onsite credit balance auditors to augment existing efforts of both Medicaid and its providers to communicate, resolve and recover claims overpayments.
Our proven recovery solutions give states comprehensive options for detecting and recovering inappropriate payments — all from one trusted and proven partner, Optum. The comprehensive Program Integrity suite from Optum includes expertise, methodologies and tools to optimize your operations and improve performance.
Prevent inappropriate payments from being made through pre-payment solutions — a more effi cient way to contain costs, particularly when coupled with traditional post-pay and recovery activities.
optum.com 13625 Technology Drive, Eden Prairie, MN 55344
All Optum trademarks and logos are owned by Optum. All other brand or product names are trademarks or registered marks of their respective owners. Because we are continuously improving our products and services, Optum reserves the right to change specifi cations without prior notice. Optum is an equal opportunity employer.
