Analytics

Our experience with the largest Medicare Advantage database of medical records in the industry informs artificial intelligence (AI):

• Suspecting: chronic conditions, new manifestations, complications, interactions
• Identification, stratification and targeting of both risk adjustment and quality care needs

Retrieval

By chart volume, Optum is the leader of Medicare Advantage risk adjustment chart retrieval. We use AI to enable chart retrieval by identifying the modality (analog or direct EHR) deemed most likely to be retrieved successfully from providers. This helps eliminate wasting time requesting charts from providers that can be retrieved digitally.

• Scale: retrieve 12 million+ charts annually
• Efficiency: EHR direct connections for chart retrieval to 150K+ providers
• Familiar provider experience: 100,000+ connected facilities, 15,000+ embedded clinics, and 3,000+ embedded hospitals

Coding and QA

Our global team of AAPC- or AHIMA-certified coders receive rigorous training and quality assurance to ensure maximum data capture and accuracy.

Accuracy:

• Integrated artificial intelligence improves accuracy and efficiency, largely eliminating the need for redundant reviews
• Coding and abstraction accuracy of over 95% annually*

Flexibility:

• Global staffing options to support variable demand year-round
• Configurable QA options to support business requirements

Submission services

We provide end-to-end management of submissions, direct errors and remediation. Insights promote continual improvement to maximize accuracy.

• Proven EDS submissions since the CMS program inception in 2011
• MA RAPS/EDS submission services to CMS
• HHS EDGE Server submission services

Audit services

Preparing for and undergoing a CMS or HHS RADV audit can be a massive task. Optum provides comprehensive data validation and support services to health plans for CMS and HHS RADV audits. We also provide internal data validation review services for clients performing self-audits and claims verification services for claims submitted to CMS and HHS.

• CMS & HHS RADV audit services
• CMS & HHS claims verification services
• Internal data validation review services for clients performing self-audits

Reporting and Insights

Optum leverages the latest business intelligence technology to deliver web-based, flexible, customizable and plan-specific insights.

• Business intelligence with comprehensive near real-time weekly, monthly and end-of-project reporting
• National disease prevalence reporting
• Program value and attribution reported by provider and member attributes
• Technology to oversee the Optum operation, and workflow tool to support health plan operations