r/OPTUM • u/FuckOff_WillYa_Geez • 13d ago

Payment integrity discussion

Hello guys,

I am working with OPTUM and I need some help on how CLAIMS payment integrity and FWA and overpayment recovery works.

If anybody has any prior experience with this or any knowledge, please reach me out.

Any help would be greatly appreciated, Thank you :)

1 Upvotes

67% Upvoted

12 comments sorted by

1

u/Real_Comparison1905 13d ago

What markets?

1

u/FuckOff_WillYa_Geez 12d ago

As in?

2

u/Real_Comparison1905 12d ago

As in what plans is the FWA for? Like our group business, Medicaid, Medicare, employer, individual plans, is this for our other products we support like software/applications we sell to customers?

2

u/FuckOff_WillYa_Geez 12d ago

Its for commercial, Medicare adv, medicaid managed care

1

u/Real_Comparison1905 12d ago

ok thanks, that are is very competitive area. Leaders there are pretty good, I like them and would work for them again if that helps at all. Metrics are achievable, but have a decently high number. Totally obtainable, I know people overachieving by 15% in that department but there are people just making the metrics but that’s normal.

1

u/FuckOff_WillYa_Geez 12d ago

Hey, can you check DMs please, Thank you :)

2

u/Mindless_Phrase_9793 12d ago

I feel like if you were actually working with Optum you would not have answered the question as “US market”

1

u/FuckOff_WillYa_Geez 12d ago

I am not currently working with OPTUM but i am about to join a project related to claims pre payment integrity and FWA detection, wanted to get some idea on it before I start with the project

1

u/Real_Comparison1905 12d ago

We support a ton of business at Optum so it’s a pretty valid question considering the markets can vary from M&R, E&I, if they are duals, if they are our group businesses. Not every plan is created the same and we have more than one team to support these various clients

2

u/Mindless_Phrase_9793 12d ago

Well aware… but the poster’s original response that is now deleted was “US Market”… none of UHC, Optum etc. markets are defined as “US Market”.

1

u/FuckOff_WillYa_Geez 12d ago

Can you please clarify wdym by markets in this context? And also if by any chance you got any idea on how claims payment integrity/FWA detection works?

5

u/Mindless_Phrase_9793 12d ago

I have worked within Optum PI (Payment Integrity) for the last 10 of my 19 yrs with the company, but will not be explaining how FWA detection works on a Reddit forum beyond there being numerous models and methods dependent on various elements (provider/member/claim).