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an expansive network and the right tools drive lower costs

According to NCCI*, 56% of the expenses related to an injury are due to office visits, surgery and anesthesia and hospital services. If you are not managing these services, you are not managing the costs or the utilization of them. That’s why Optum offers Medical Services that include a network of hospitals, physicians, clinics and specialists who are credentialed and vetted to ensure quality care at an appropriate cost. Working in conjunction, our Clinical Case Management, Bill Review, and Clinical and Coding Logic services increase medical savings by streamlining workflows, improving efficiency and giving insights into each claim.

* Source: NCCI (October 2018). Medical Services and How They Contribute to the Cost of WC Claims. Retrieved from https://www.ncci.com/Articles/Documents/II_Insights-MedicalServicesWCClaims.pdf

Want to learn more about Optum Medical Services? Explore the information below.

Supplements network strategies to increase savings. Our experienced professionals leverage data and automated processes to complete timely, accurate, clinical reviews.

Go beyond typical bill review and dig deeper into billed charges at the line level to identify errors and patterns of inappropriate billing. We address market gaps in payment integrity.

Our exclusive connection with UnitedHealth Group's OneNet® network helps increase in-network transactions, drive data integrity and simplify
claim administration.

With the first report of injury, our Clinical Case Management program establishes a claimant advocate who coordinates
and channels care, with accessible and experienced network providers.


Bill Review

Medical bill review supplements network strategies to increase savings even more. Our knowledgeable and experienced in-house professionals leverage data and automated processes to complete timely, accurate, professional-level clinical reviews.

As a result, you will realize maximum savings as the process:

  • Combines national coverage capabilities with regional networks
  • Applies national coding parameters
  • Detects improper billing practices and duplicate entries
  • Integrates all utilization review decisions into the medical bill review process

Like many of our programs, medical bill review services can be integrated with other products, such as PPO and speciality networks or provided on a stand-alone basis.


CLINICAL & CODING LOGIC

Optum goes beyond typical medical bill review, digging deeper into billed charges at the line level to identify errors and patterns of inappropriate billing. We address market gaps in payment integrity through our Clinical & Coding Logic Solution. Our solution includes incremental rules and edits that exist above and beyond industry standard bill review edits found in most review platforms. This additional rule logic is based on coding foundations and principles sourced to the American Medical Association’s CPT guidance, Medicare methodology, specialty society guidance, our proprietary database for implant/supply costs, industry benchmarks, and national payers’ payment schedules. 

Our line-by-line reviews include:

• Medical necessity
• Coordination of benefits
• Appropriateness
• Clinical coding edits

• Bill validation
• Pre-existing conditions
• Fee schedule compliance

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PREFERRED PROVIDER ORGANIZATION (PPO)


Optum has an expansive national network of providers of physicians, specialists, physical therapists, chiropractors, home health providers, hospitals and clinics that provide treatments for workers’ compensation and auto no-fault injuries. The network includes our proprietary, directly-contracted Procura™ PPO network, an exclusive connection with UnitedHealth Group's OneNet®, as well as numerous affiliate network partners to increase our footprint and improve access to care nationwide. Our network structure incorporates best-in-class savings and penetration by region, greater network penetration at preferred rates, improved outcomes for customers, and simplified administration for adjusters and payers.

With the Procura PPO network our clients benefit from:

  • Exclusive connection with UnitedHealth Group's OneNet® network in DC, DE, FL, GA, MD, NC, PA, SC, TN, VA, and WV, with plans for expansion
  • Preferred partnerships to key networks and providers of OptumCare® 
  • Maximum provider penetration and savings with access to 22 affiliate networks
  • Accurate and current demographics and status of current providers
  • Integrated physician dispensing program through network operations
  • Customized solutions on a state-by-state basis
  • Exceptional customer service and a dedicated staff 

CLINICAL CASE MANAGEMENT

Starting with the first report of injury, our Clinical Case Management program establishes a claimant advocate who coordinates and channels care, where permitted, with accessible and experienced network providers.

This helps to make certain medical treatment is:

  • Managed proactively based on recognized medical guidelines and evidence-based medicine
  • Safe, cost-effective and designed to promote recovery
  • In accordance with program parameters and jurisdictional regulations
  • Compassionate and well-coordinated to alleviate concerns and promote adherence