Optum has introduced a new artificial intelligence system designed to overhaul the complex and often slow process of medical claims and reimbursement. The new tool, named Optum Real, provides healthcare providers with the ability to verify a patient's health benefits in real time, aiming to reduce claim denials and increase financial transparency for patients.
The system is already being implemented by UnitedHealthcare, the insurance division of Optum's parent company, UnitedHealth Group. Additionally, Allina Health, a major healthcare provider in the Midwest, is piloting the technology for its radiology and cardiology departments, where it has already been used in over 5,000 patient visits.
Key Takeaways
- Optum has launched Optum Real, an AI-powered platform for real-time medical claims processing.
- The tool aims to provide immediate information on patient benefits, potentially reducing claims denials.
- UnitedHealthcare is the first major insurer to adopt the system.
- Allina Health is piloting the technology in its radiology and cardiology services, with over 5,000 visits processed so far.
- The system is designed to prevent conflicts between payer and provider systems by creating a unified data exchange.
A New Approach to an Old Problem
The administrative side of healthcare represents a significant financial burden on the U.S. system. Billions of dollars are spent annually on managing financial transactions, including claims processing, prior authorization requests, and billing. This complex process often leaves patients uncertain about their coverage and potential out-of-pocket costs until weeks after receiving care.
Optum's new platform seeks to address these inefficiencies directly. By enabling real-time communication between healthcare providers and insurance payers at the point of service, the system can identify potential coverage issues or errors before a claim is even formally submitted. This proactive approach is a departure from the traditional model, where issues are typically discovered long after a patient has left the clinic.
How Optum Real Works
The Optum Real platform leverages artificial intelligence to analyze vast amounts of data from payer contracts and clinical guidelines. When a provider enters information about a planned service, the system instantly cross-references it with the patient's specific insurance plan. It can then validate coverage and flag any potential problems immediately.
This allows administrative staff to resolve issues on the spot, such as confirming whether a specific procedure is covered or if a prior authorization is needed. For patients, this means greater clarity about their financial responsibility before they commit to a service, reducing the likelihood of unexpected medical bills.
The High Cost of Administrative Waste
The U.S. healthcare system is known for its administrative complexity. Studies have shown that administrative costs account for a substantial portion of total healthcare spending. These costs include tasks like billing, processing insurance claims, and managing records. Inefficiencies in these areas not only increase costs for the entire system but also contribute to provider burnout and patient frustration.
Preventing a Digital Arms Race
The integration of AI into healthcare administration has been a major topic of discussion, with many seeing it as a solution to workforce shortages and overwhelming paperwork. However, a potential pitfall is the development of competing AI systems by payers and providers, which could lead to a new form of digital conflict.
Puneet Maheshwari, general manager of Optum Real, highlighted this concern at the HLTH 2025 conference in Las Vegas. He noted that if payers and providers simply deploy their own separate AI tools to manage claims, the fundamental problem of a lengthy, adversarial process will remain.
“Today, it’s my rule-based system against your rule-based system,” Maheshwari explained. “Tomorrow, it’s going to be my AI versus your AI.”
Optum Real aims to prevent this scenario by creating a shared platform for data exchange. Instead of two systems battling over a claim, both parties can access the same validated information in real time. This collaborative approach is intended to reduce friction and eliminate the guesswork that often leads to delays and denials.
Pilot Program Shows Early Promise
The initial implementation at Allina Health, which operates 12 hospitals and more than 90 clinics, has already processed over 5,000 patient visits using the Optum Real system. The pilot is focused on radiology and cardiology, two specialties that often involve complex billing and prior authorization requirements.
The Impact on Patients and Providers
For healthcare providers, the primary benefit of a real-time system is the reduction of administrative burden and the improvement of cash flow. Denied claims are a major source of lost revenue and require significant staff time to appeal and resubmit.
By catching errors at the source, providers can ensure they are submitting clean claims that are more likely to be paid promptly. This frees up administrative staff to focus on more complex patient-facing tasks rather than chasing down payments.
Greater Transparency for Patients
From the patient's perspective, the new technology promises a much-needed dose of transparency. One of the most common complaints about the healthcare system is the unpredictability of costs. Patients often undergo procedures without a clear understanding of what their insurance will cover.
A system that can provide immediate feedback on benefits and coverage allows for more informed decision-making. Patients can discuss costs with their provider upfront and explore different options if a particular service is not covered, leading to a more positive and less stressful healthcare experience.
The Road Ahead for AI in Healthcare Billing
The launch of Optum Real is part of a broader trend of applying AI to solve some of healthcare's most persistent administrative challenges. As these technologies become more sophisticated, they have the potential to fundamentally change the financial interactions between patients, providers, and payers.
With UnitedHealthcare, one of the nation's largest insurers, on board, the adoption of Optum Real could set a new standard for the industry. If the system proves successful in reducing administrative waste and improving the patient experience at scale, other insurers and health systems will likely follow suit, accelerating the shift toward a more efficient and transparent healthcare financial system.
