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. 

The current system of detecting fraud, waste and abuse post payment and attempting recovery at that time is expensive, unreliable and unsustainable. Integrating fraud risk controls at the front end of the process helps you proactively prevent fraud in today’s complex health care environment.

Optum offers prospective claims analysis that goes beyond standard claims analytics to help you discover latent patterns and relationships before payments are made. Our comprehensive prepayment fraud detection solution not only helps you proactively deter fraudulent activities but enables you to differentiate yourself as a difficult target for false claim submissions. We help you investigate prepayments thoroughly to lower costs without disrupting the overall claims process or compliance regulations related to prompt payment.

In conducting our prospective claims analyses, we use predictive analytics to: 

  • Build mathematical equations and algorithms to flag suspicious claims
  • Identify providers who demonstrate irregular billing trends and patterns
  • Review medical records to recommend payment or denial
  • Identify policy violations and prevent claim payments

By partnering with Optum and deploying our full spectrum of fraud, waste and abuse detection services, you may:

  • Save substantial money by preventing abusive claims through accurate investigation and recovery processes.
  • Optimise your return on investment by leveraging the extensive clinical knowledge of our anti-fraud professionals, including physicians, nurses, doctorate-level statisticians and certified professional coders.

Call us today to learn how Optum can help you prevent fraud, waste and abuse through prospective analysis and predictive analytics.