Regulatory compliance

Helping health plans comply, adapt and grow in the post-reform era


Health plans are faced with an increase in regulatory mandates. With many of these reforms underway, plans are assessing the implications and making course corrections to take advantage of the unprecedented growth opportunities and to optimize all facets of their operations.

Optum has unparalleled experience and a suite of compliance solutions to help plans meet these reform and compliance goals.

Our expert consultants are skilled at extending regulatory compliance and technology investments to further drive positive impacts to the front office, care management and the back office, and provide for market differentiation.


Optum regulatory compliance solutions help health plans:

  • Achieve smooth and timely transition to regulatory reforms
  • Enter and profitably compete in the exchange marketplace
  • Pivot to a consumer-centric health care model
  • Manage risk and quality performance for sustainable growth
  • Reach optimal operational and administrative efficiencies

Services include:

ICD-10 — Health plans need to transition from ICD-9 to ICD-10. Optum offers a complete solution to help you move forward strategically to achieve compliance, stabilize your operation and optimize payment, benefit, revenue, clinical operations and financial functions.


HIX Edge Server Services — To help mitigate adverse selection and premium volatility and to comply with risk adjustment and reinsurance data collection mandates, health plans are required to regularly submit claims and enrollment information to the Department of Health and Human Services (HHS). Optum offers full-service support designed to ensure accurate, timely compliance and avoid risk.


Public health insurance exchange — Health plans need unique strategic and execution capabilities to enter and compete in the exchange marketplace. Optum offers solutions to help health plans succeed on the state-based and federally facilitated marketplaces with capabilities spanning operational, financial and market assessments, consumer engagement, enrollment and payment reconciliation, and risk adjustment and reinsurance data collection.