Optum, an industry leader in health care payment integrity services, is
working with SAS to further enhance its comprehensive health care
anti-fraud, waste and abuse services. This enhanced solution combines
detection, investigation, prevention, case development and recovery
services to provide commercial health plans with a flexible approach to
ensuring proper payments to care providers.
While the vast majority of health care spending reflects the actual
costs of patient care and medical services, the National Health Care
Anti-Fraud Association (NHCAA) estimates that $60 billion is lost
annually to health care fraud, waste and abuse. This figure includes
such activities as billing for unperformed medical services; performing
a medically unnecessary test or procedure; billing for more expensive
medical services or procedures than the one conducted; or billing each
stage of a procedure in place of a bundled rate.
"Health plans find it challenging to assemble the complex combination of
technology and talent required to mount sophisticated anti-fraud
defenses," said Nick Howell, Optum's senior vice president of
operational and administrative efficiency. "By working with SAS, we can
further enhance our support of payers seeking to access most
sophisticated analytics, the largest datasets, and the largest
investigative operations in the industry."
The Optum solution uses SAS's Fraud Framework and Optum's deep health
care expertise and extensive health care claims and fraud case datasets
to identify and prevent instances of fraud, wase and abuse for payers.
The solution delivers broad detection capabilities including rules,
flags, predictive modeling, text mining and social network analysis to
identify possible instances of provider and consumer fraud, including
multi-party fraud schemes and organized crime.
"This solution has a proven track record of detecting improper payments
early and stopping them before they negatively impact the health care
system," said Julie Malida, principal for Health Care Fraud Solutions,
SAS. "Together, SAS and Optum are uniquely positioned to help the
industry address the growing issue of health care fraud, waste and
abuse, which shows no signs of abating without intervention."
"Health care payers that adopt an enterprise approach to fraud
prevention help their organizations realize immediate operational cost
recovery, and enable greater savings over time," said Christina Lucero,
principal research analyst for commercial health plans at Gartner, Inc.
"Partnerships that integrate both health care experience and new
technologies provide the greatest opportunity for change in the way we
traditionally address fraud and abuse, enabling focus on prevention vs.
Specific benefits of this solution include:
About OptumOptum (www.optum.com)
is a leading information and technology-enabled health services business
dedicated to helping make the health system work better for everyone.
Optum comprises three companies - OptumHealth, OptumInsight and OptumRx
- representing over 35,000 employees worldwide who collaborate to
deliver integrated, intelligent solutions that work to modernize the
health system and improve overall population health.
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