Payment integrity

Simplify systems to reduce costs and increase accuracy

We proactively drive payment integrity, and improve provider relationships and member experience. Our solutions transform end-to-end claims processing performance by simplifying the payment system, improving accuracy and reducing costs.

With this holistic approach, we can help:

  • Identify and recover inappropriate claim payments and overpayments
  • Simplify and reduce the administrative cost of the payment cycle
  • Avoid and prevent inappropriate claim payments and overpayments
  • Drive out unnecessary and inappropriate medical costs
  • Outsource payment cycle services, enabling plans to focus on core competencies

Our comprehensive software and services include pre-payment, payment and post-payment solutions.




Assessment and optimization

We can help you implement a well-coordinated enterprise payment integrity program that will both identify pre- and post-payment claims processing problems. Such a system will also yield actionable intelligence for systemic improvements that will improve accuracy, lower costs and improve provider satisfaction.

Payment integrity is a strategic imperative.

The strategic payment integrity approach:

  • Cuts operating and medical expenses.
  • Mitigates future risk.
  • Retains member and provider loyalty.

Claims editing

Power claims editing technology

Optum™ Claims Edit System provides an extensive set of core rules that utilize historical data to maximize your auditing capabilities for commercial, Medicaid and Medicare claims. More than an unbundling and editing tool, this system features flexible editing functions and complete customization capabilities, so you can create unique auditing logic to implement your proprietary business rules.

Prospective Payment Solutions

Compliant and cost-efficient reimbursement

By using the established framework of Medicare’s Prospective Payment System (PPS), health plans share the risk with their provider network, making each group accountable for the portion of risk that they can effectively manage.

Fraud, waste and abuse services

A flexible approach to detection, investigation, case development, management and recovery services.

From cost avoidance (pre-pay), to cost recovery (post-pay), fraud, waste and abuse services by Optum™ provides data, analytics, technology and expertise scaled to meet your needs.

Subrogation and injury coverage coordination

Maximize savings and recoveries with accurate identification and effective prevention strategies.

Subrogation Services and Injury Coverage Coordination Services from Optum™ help identify, prevent, investigate and recover accident-related medical and disability claims expenses to determine the responsible party for bearing claim payment liability.

Recovery services

Optum recovery services offer the only multifaceted approach to address payers’ unique collection needs. Our long-standing relationships with providers and health plans allow us to resolve inventory quickly, going beyond expediting recovery to focus on complete claims resolution. By leveraging our expertise and technology, we help plans reduce administrative and medical costs, analyze long-standing issues and recommend process improvements.

Coordination of benefits

Identify and validate other insurance coverage.

Optum™ Prospective Coordination of Benefits helps reduce costs and eliminate administrative complexity by identifying and validating other coverage insurance (OCI) and determining the order of primacy for members prior to paying the claim.

We’re ready to put our platform to work for you. Let’s start the conversation.
Contact Us 1-866-386-3404

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