Case Study: Large Southeast-Based Healthcare Company recovers retroactive ESRD payments and boosts payment integrity with Optum

Large Southeast-Based Healthcare Company - Customer Case study

Large Southeast-Based Healthcare Company engaged Optum to assess payment and revenue integrity across its government programs (senior market and Federal Employee Program). The payer faced time-constrained resources, departmental siloes, and lacked reliable tracking for members with End Stage Renal Disease (ESRD), which prevented timely filing of physician forms required by CMS and risked missed payments.

Optum’s consulting team performed a three-month Payment and Revenue Integrity Assessment—reviewing claims payment, auditing, reporting and analytics, clinical care management, enrollment, reconciliation, and Star Ratings—and recommended process refinements, cross-functional collaboration, and fixes to overpayment recovery and audit policies. Optum uncovered a major revenue opportunity by identifying untracked ESRD members—eligible for CMS payment increases worth thousands of dollars per member per month, retroactive up to six years—helping the client improve payment accuracy and begin recovering significant funds even before the engagement ended.