Fraud and Abuse Detection System

Prevent, detect and recover

Optum™ Fraud and Abuse Detection System (IFADS), is a solution suite comprised of tools designed to help manage fraud and abuse investigations from detection through collection. When all components are installed, IFADS allows jurisdictions to meet 100 percent of the CMS Program Integrity Business Area Checklist requirements.

IFADS provides advanced analytical models that identify patterns in claims data, which are often indicative of fraud, abuse, error, and waste. IFADS includes a powerful Optum Surveillance and Utilization Review System (ISURS), which provides on-demand, real-time, peer-to-peer comparisons of provider billings, and recipient utilization of services.

IFADS can help you:

  • Identify potential fraud and abuse, track investigations and recoupments
  • Research unusual behaviors, with a minimum of false positives
  • Confidently pursue irregular activity on the part of both providers and recipients

The Optum Fraud and Abuse Detection System (IFADS) is a solution suite comprised of:

Optum Surveillance and Utilization Review System (ISURS)

Optum SURS is a flexible, web-based component used to create meaningful peer group profiles that deliver actionable results. ISURS features a user-friendly interface and a wizard that enables users to easily build and run their own studies without technical help from their desktops and get results within hours.

Enhanced fraud analytics

The Optum Enhanced Fraud Analytics component features advanced mathematical analytics and models that compare claims to identify fraudulent or abusive claims. These powerful data mining solutions automatically sift through vast quantities of claims data to detect unusual patterns, which are often indicative of fraud as well as pinpoint providers with questionable behavior to help organizations ensure claims accuracy.

Case tracking

This easy-to-use case tracking tool tracks, documents, and supports investigation and recovery activities. With the case tracking component, state staff can combine study results, case tracking notes, and external documents in a single electronic folder.

Provider activity spike detection

The Provider Activity Spike Detection Component automatically evaluates the entire provider population in a state to identify those providers who have had large increases or decreases in billing activity, for example claims paid, dollars paid, or beneficiaries serviced.

Random sampling

The Random Sampling component provides users with a robust, statistically valid, and court-tested capability to draw random samples of claims, providers, or beneficiaries. With this component, users can quickly and easily create a random sample from within the IFADS solution itself, eliminating the need for a third-party statistical application.

Easy-to-use technology

IFADS also includes additional functionality, including Browse and Search Reports, online reference code lookups, “top N” reports (by procedure code, diagnosis code, and NDC), “dollars by month/quarter/year” reports, provider and client demographic information, links to current fraud and abuse articles, and robust online help.

The Optum Fraud and Abuse Detection System (IFADS) is a user-friendly suite that speeds analysis efforts and increases productivity — resulting in successful recovery efforts and accurate payments. Using this powerful solution helps investigators:

  • Perform advanced profiling — ISUR includes a full complements of reports with drilldown capability that allows users to navigate from a summary total to claim detail with the click of a mouse
  • Build SUR studies — With the ISUR Wizard, building a basic but useful study can be completed in minutes based on state-defined provider types and provider’s role on a claim
  • Conduct advanced fraud analytics — The Enhanced Fraud Analytics component employs comprehensive analytical strategies and advanced technology to identify suspect medical claims, non-compliance, and health care fraud, abuse, and waste
  • Manage investigative activities — Using the Case Tracking functionality, state investigators can track and report fraudulent activities, collect and document information, and maintain supporting result sets online
  • Identify significant changes in provider billing activity — The Spike Detection component automatically identifies providers with exceptionally large increases in claim volume and billings
  • Generate simple random samples — IFADS provides users with a robust, integrated capability to draw random samples of claims, provider, or client information without leaving the IFADS component and generate random samples from an entire universe of claims or from a subset
  • Simplify data analysis — The Browse and Search component is an “ad hoc-lite” application that enables users to easily retrieve, sort, and filter information and incorporates a broad range of drilldown reports, allowing staff to perform powerful analysis simply by clicking on embedded hyperlinks
  • Meet CMS Program Integrity Certification Requirement — Combining IFADS with treatment grouping technology enables investigation staff to demonstrate compliance with CMS Program Integrity Certification Checklist requirements — contributing to an overall CMS Certification of the jurisdiction’s MMIS system