Accurate claim payment can be challenging
The dynamic and complicated nature of health care can lead to a high potential for fraud, waste, abuse and error. And many factors magnify this inherent complexity, including:
- Changing regulations by governing bodies such as the Centers for Medicare & Medicaid Services
- Confusing and ambiguous payment policies
- Detailed and customized provider contracts
- More than 85,000 diagnosis codes
- Multiple forms of reimbursement
Comprehensive claim review
See how Optum® Claim Review combines pre- and post-payment technology and expert services to maximize savings, reduce repeat errors and minimize provider abrasion.
End-to-end claim review
Our comprehensive suite of solutions is available both pre- and post-pay to catch errors at every step in the claim lifecycle.
Data Mining
Identify claim errors and overpayments related to duplicates, coordination of benefits, billing issues and contract administration.
Professional Claim Review
Identify coding errors, such as upcoding and unbundling, on professional claims by comparing charges against a medical record.
Facility Audit
Validate coding and clinical accuracy on inpatient and outpatient facility claims by comparing charges against a medical record.
Itemized Bill Review
Identify errors on high-dollar inpatient and outpatient claims with a line-by-line review of the itemized bill.
Hospital Bill Audit
Validate high-dollar inpatient claims against the itemized bill and medical record.
Short-Stay Billing Validation
Identify ambulatory or outpatient claims incorrectly billed as inpatient.
Drive more results from your claim review program
Our pre- and post-pay Claim Review solutions combine advanced technology and human expertise to prevent improper payments, reduce medical spend and minimize provider abrasion. Our results:
- 100% of claims are risk-scored daily
- True positive rates can approach 70% or more
- Less than 2% of appeals are overturned
- 2-5% of medical expenses saved with integrated pre- and post-pay solution