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:

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