Optum and SAS Align to Help Prevent Health Care Fraud, Waste and Abuse

  Optum and SAS Align to Help Prevent Health Care Fraud, Waste and Abuse

Enhanced anti-fraud, waste and abuse solution builds upon Optum solutions that
              saved $500 million for health plan clients in 2011

Business Wire

EDEN PRAIRIE, Minn. -- December 10, 2012

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

“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, waste 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. pay-and-chase methods.”

Specific benefits of this solution include:

  *Reduced investment: The solution does not require users to purchase,
    install or maintain software. This means a reduced investment for health
    plans in terms of both time and capital – and extends the capabilities to
    mid- and smaller-sized plans.
  *Improved detection speed and accuracy: The solution applies a broad range
    of analytics, both prospectively (pre-pay) and retrospectively (post-pay),
    to scan more than 1 million claims per day to improve detection efforts
    and find fraud quickly and accurately. These advanced, proprietary
    analytics include anomaly detection, predictive modeling, social network
    analysis, text mining and rules to filter out fraudulent, wasteful and
    abusive transactions.
  *Integrated detection, investigation, case development and recovery
    services: The framework provides access to Optum’s extensive clinical,
    investigative and recovery resources, including more than 600 anti-fraud,
    waste and abuse professionals. Optum’s multi-disciplinary staff combines
    medical experts, certified professional coders, statisticians and special
    investigative unit professionals.

About Optum
Optum (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.


Christine Farazi, 952-917-7538
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