Using AI and expertise to elevate payment integrity
Powerful analytics and health care expertise
Optum is the first in the market to use machine learning in advanced predictive models. Our approach detects, reviews and reports opportunities for pre-payment prevention. It also facilitates post-payment audit and recovery efforts.
Learn how Optum employs AI to make an impact in payment integrity. Click through this interactive infographic.
Powerful analytics and health care expertise – Text Version
Analytics provider flags models
Trends
Changes in the volume or composition of claims detected are analyzed to identify areas of opportunity to increase savings and manage program impacts to individual providers.
Alerts
The highest risk claims detected are scored, suspended for review and routed to coding and policy experts for validation.
Feedback
Detailed medical record review findings are sent back to the detection engine to improve the machine learning models.
Performance
Medical record review outcomes data powers reporting on detection performance, e.g., true positive rates and savings per claim reviewed, and quality metrics for review operations.