Prevention and Detection - Chapter 16, 2020 UnitedHealthcare Administrative Guide

Prevention and Detection

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