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