Claims Validation in Action
See how Claims Validation combines pre- and post-payment technology and expert services to maximize savings, reduce repeat errors and minimize provider abrasion.
No claim should process without validation
Many factors magnify claims validation complexity including:
- Ever-changing CMS rules
- Confusing and ambiguous payment policies
- Detailed and customized provider contracts
- Over 85,000 diagnosis codes
- Multiple forms of reimbursement
Our pre-payment validation uses predictive scoring with advanced machine learning to systematically analyze all claim types for billing errors. It suggests a hold, pend or deny action. All of this occurs after claims have been adjudicated but prior to payment.
Our post-payment validation process aligns with our pre-payment validation to conduct look-back reviews of claims paid prior to instituting a pre-payment validation process.
Post-payment validation continues to identify claims with errors not appropriate for a pre-pay audit. Certified coding professionals can conduct post-payment audits onsite or remotely.
What makes our Claims Validation unique?
We can validate all professional and facility claims and offer both pre- and post-payment reviews to maximize results. Our validation includes daily predictive scoring to:
- Accurately and quickly identify potential errors
- Flag providers
- Validate charges
- Reduce repeat errors
We cast the widest net to catch fraud, waste, abuse and errors along the payment lifecycle. Applying pre-pay and post-payment validation and audits is more effective. It also reduces provider abrasion and optimizes your results.
![Predictive scoring models, provider flags; DRG, outpatient, carve-out validation, analytics](/content/dam/optum4/images/business/health-plans/blocks/wf3418088-claims-validation-savings-graphic-1080x720.jpg)
Claims Validation results
We have an unmatched ability to select the right claims for audit:
- 100% of your claims are risk scored daily
- Our true positive rates can approach 70% or more
- Less than 2% of appeals are overturned
Our integrated pre- and post-payment solution can save 2–5% of your medical expenses. This could generate hundreds of millions in medical expense savings each year.
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