Optum is committed to making health care better for everyone. Consumers, providers, payers and purchasers are all negatively affected when Fraud, Waste, Abuse, or Error (FWAE) occurs anywhere in the system. Instances of Waste or Abuse may be unintentional, resulting from a variety of causes including limited knowledge about best practices or delays in implementing new processes that would improve efficiencies. Errors are mistakes, inaccuracies or misunderstandings that can usually be identified and fixed quickly. Fraud, on the other hand, is the result of intentional misrepresentation to gain a benefit. Everyone involved in health care can take steps to reduce the cost of fraud, waste, abuse and error.
Optum has a Program and Network Integrity (PNI) team within our organization. This team works with Providers to identify billing as well as payment patterns and trends which may require education or modification of practices or processes on the part of the Provider or Optum. Together with Providers, Optum is committed to identifying and remediating potential Fraud, Waste, Abuse and Error and Payment Integrity Issues.
PNI Mission Statement
It is Optum’s mission and intent to protect members, providers, business partners, employees and stakeholders by administering a strong and effective anti-FWAE program designed to prevent, detect, investigate and resolve incidents of potential FWAE, with a focus on education and prevention. Our Company is committed to addressing and correcting known offenses, recovering lost funds, improving overall anti-FWAE ability and partnering with state and federal agencies to pursue and prosecute violators to the fullest extent of the law. Optum supports this commitment to protecting members, providers and other healthcare stakeholders through technologically advanced tools and the administration of a strong and balanced review process to ensure industry standards regarding documentation and billing of services are met.
Guidance and Resources
This page is intended to provide guidance and resources related to documentation requirements. In addition, we want to remind you that we have an audit process related to billing and coding.
Documentation and Payment
Please review the materials posted below under Education and Training. It includes some resource links to help you more readily access information about the codes and, in particular, materials aimed at supporting documentation of services. Documentation is critical to ensure proper payment of the services rendered. In the event of an audit, claim submissions with records that do not support the code billed will be denied or recouped. You will then have the option of either submitting a corrected claim for the services as supported by the documentation provided for the audit, or submit an appeal with additional supporting documentation.
Any request for documentation is used to verify the services billed are recorded in a manner consistent with industry guidelines. In line with HIPAA rules associated with Treatment, Payment and Operations, Progress Notes may be required to complete the audit. Progress notes should include, but are not limited to: Medication prescription monitoring (if applicable), functional status, symptoms, session start and stop times, modalities and frequency of treatment furnished, clinical testing results (if applicable) and a summary of the following: diagnosis, treatment plan/goals, prognosis and progress to date. Any additional information that is necessary to support the services billed should also be provided at this time.
How You Can Help
- Be Informed
Become familiar with key definitions, review Optum’s Network Manual section on FWAE, read articles on the topic (some links provided here), talk with colleagues and participate in training opportunities on a regular basis. Combatting FWAE is a role for all mental health professionals to support appropriate access to care and application of available funding of those services.
- Report Potential FWAE
Anytime there is a suspicion of potential Fraud, Waste, Abuse or Error, please report it immediately. The sooner Optum receives the referral, the sooner we can intervene. Your insight and awareness to potential Fraud, Waste, Abuse and Error, along with reporting, supports all members receiving care and the proper use of available funds to maximize success.
Definition of Fraud, Waste, Abuse and Error
- Fraud is an intentional misrepresentation to gain a benefit
- Waste is any unnecessary consumption of health care resources
- Abuse is unsound business practice that results in undue remuneration
- Errors are mistakes, inaccuracies or misunderstandings that can usually be identified and fixed quickly
Definition of Payment Integrity
Optum proactively drives payment integrity to improve provider relationships and member experience. The solutions transform end-to-end claim processing performance by simplifying the payment system, improving accuracy and reducing costs.
With this holistic approach, we can help:
- Identify and recover inappropriate claim payments and overpayments
- Simplify and reduce the administrative cost of the payment cycle
- Avoid and prevent inappropriate claim payments and overpayments
- Drive out unnecessary and inappropriate medical costs
- Outsource payment cycle services, enabling plans to focus on core competencies
Our comprehensive approach includes pre-payment and post-payment solutions.
FWAE section of the Network Manual: Fraud, Waste, Abuse and Error
Training and Education Materials
- E/M Codes and Psychotherapy Documenting Your Work
- E/M Coding Office-Based Services
- E/M Initial and Subsequent Hospital Care
- E/M Initial Observation Care
- E/M Inpatient Consultation
- E/M Observation or Inpatient Hospital Care
- E/M Office Consultation
- Laboratory Drug Screening Services
Prospective Claim Reviews – Edits Information Sheets
- CMS Medicare Learning Network: Medicare Fraud & Abuse – Prevention, Detection and Reporting
- CMS Fact Sheets: Lower Costs, Better Care – Reforming our Health Care Delivery System
- CMS Medicare Learning Network: MLN Provider Compliance > Downloads > Medicare Parts C and D Fraud, Waste, and Abuse Training and Parts C and D General Compliance Training
- Office of Inspector General: Spotlight on Fighting Fraud at Community Mental Health Centers
External Resources (Government Agencies, Coalitions, Professional Associations)
- CMS – The Deficit Reduction Act
- Medicare.gov – Report fraud & abuse
- Help Fight Medicare Fraud (Medicare.gov)
- Office of Inspector General – Report FWA
- U.S. Department of Justice – False Claims Act Primer
- Coalition Against Insurance Fraud
- National Health Care Anti-Fraud Association® (NHCAA)
- Taxpayers Against Fraud – False Claims Act
Contact Information for the Program and Network Integrity
E -Mail: firstname.lastname@example.org
Mail: P.O. Box 30535, Salt Lake City, UT 84130-0535
General inquiries (communications to PNI other than TIPs): email@example.com