Prevention and detection - Chapter 17, 2021 UnitedHealthcare Administrative Guide

We help prevent and detect potential FWA through many sources. These include:

• UnitedHealthcare payment integrity functions
• Optum companies within UnitedHealth Group
• Health care providers
• Health plan members
• Federal and state regulators and task forces
• News media
• Professional anti-fraud and compliance associations
• CMS websites: sam.gov/SAM

We also monitor and audit prevention and detection by:

Prospective detection:

• Pre-payment data analytics
• Data mining queries
• Abnormal billing patterns
• Other activities to determine if we need additional prospective activities

Retrospective detection:

• Post-payment data analytics
• Payment error analytics
• Industry trend analysis
• Care provider audits