Overview
- Optum reviewed $9.4 billion in fee-for-service claims across 14 high-risk Medicaid services from January 2022 through October 2025, identifying $52.3 million that violated clear policy.
- The report estimates about $1.7 billion in payments as potentially vulnerable due to unclear policies or possible billing issues, which require record-level review and are not evidence of fraud.
- Early autism intervention centers were a major factor, with more than 90% of their claims not clearly matching policies and roughly $1 billion of the potential savings tied to that category.
- DHS is deploying AI-enabled prepayment screening and automated claims editing, is reviewing roughly 100,000 claims every two weeks, and has denied more than 70 in the first cycle without fraud findings.
- The department will revalidate about 5,800 providers through unannounced site visits as CMS conducts a separate audit and seeks a $2 billion funding withhold that Minnesota is appealing.