Retrospective Fraud and Abuse Recovery

Effective detection and recovery

Detecting health care fraud isn’t easy. Unfortunately, after-the-fact collections are rarely paid in full due to resource limitations and the volume of data involved. Optum Retrospective Review and Recovery services includes sophisticated fraud detection technology and predictive analytics examine historical claims to identify patterns and trends that signify fraudulent or abusive activity for review by government staff. Optum experts can help you more effectively detect and recover claims overpayments resulting from fraud and abuse.

Maximize your investment

Most health care payers have used traditional “pay and chase” strategies to manage fraud and abuse after a claim has been paid. However, case development and recovery efforts require significant expertise and technology. The experts at Optum™ have the resources to examine thousands of providers and claims in minutes to analyze past behaviors and flag suspicious patterns. Our insights can save you money.

To fully develop a case, we perform services such as:

  • Medical record audits
  • Provider verification
  • Trending
  • Financial loss quantification
  • Department of Insurance (DOI) reporting

Recovery

Optum performs an evaluation on each case to determine the best strategies for further overpayment recovery actions. For cases that progress into the recovery stage, our experienced team of professionals conduct a deeper level of investigation until we find what we're looking for. Then, we coordinate recovery negotiations, arrange settlement agreements and recover the dollars that are rightfully yours. Finally, we present you the check.

The Value of experience

We have reviewed aberrances and/or referral allegations associated with 1.4 million providers and 20 million members on more than 200 million claims. We bring extensive knowledge and experience to the process.