Fraud, waste and abuse analytics

Our retrospective fraud detection services analyse large volumes of historic claims data to identify irregular billing patterns and suspicious providers.

A recent study of the Indian health insurance market estimates that 10 to 15 percent of health insurance claims are fraudulent, costing the Indian health care industry close to Rs. 600–800 crores annually. With instances of fraud, waste and abuse on the rise, a comprehensive solution is needed to ensure quality of care is not affected and health care costs do not increase.

OptumTM provides advanced fraud, waste and abuse detection services meeting Indian compliance regulations. Our fraud, waste and abuse analytics identify and address irregular claims throughout the claims lifecycle. We tailor our solutions to the size and scope of your operation, integrating analytics, operations and technology to help prevent financial fraud, waste and abuse.

The Optum approach focuses on:

  • Predictive analytics. We leverage robust statistical models to identify patterns and trends in fraud, waste and abuse. Through predictive analysis, we develop algorithms to flag suspicious claims and prevent future fraud. 
  • Prospective prevention. As claims come in, we use predictive analytics to flag suspicious claims to prevent inappropriate payments. 
  • Retrospective detection. We analyse paid claims to detect abnormal billing patterns and identify suspect providers. Suspicious claims are flagged for review and recovery.
Optum offers health information technology, risk management and analytics expertise
 

Optum offers a comprehensive HIT foundation for enhanced risk management. Our fraud, waste and abuse services provide:

  • Domain expertise. Our solution leverages expertise in programme integrity as well as advanced clinical and statistical knowledge.
  • Advanced analytics. Our retrospective, prospective and predictive analyses help improve claims payment accuracy, thereby increasing business performance and profitability.
  • Flexible partnership models. Our agile delivery models are flexible and scalable, based on your specific requirements.

Contact us today to learn how Optum fraud, waste and abuse detection services can help you.

Predictive analytics

We use predictive analytics to detect and prevent fraud, waste and abuse.

Through predictive analytics, we help health care organisations fight fraud, reduce waste and mitigate risk.

Prospective fraud detection

We analyse claims prepayment to detect erratic patterns and prevent improper payment.

We use prospective claims analysis to help health care organisations discover fraudulent claims before paying them. 

Retrospective fraud detection

We help you identify suspicious claims patterns and recover improper payments.

Our retrospective fraud detection services analyse large volumes of historic claims data to identify irregular billing patterns and suspicious providers.