LexisNexis® Risk Solutions today announced the company has been selected by Harvard Pilgrim Health Care – the number one private health plan in America for the last 10 years according to the National Committee for Quality Assurance (NCQA) – to help detect, investigate and recover fraudulent claims. LexisNexis Intelligent Investigator™ and Trail Tracker™ solutions provide Harvard Pilgrim’s Special Investigative Unit (SIU) an enterprise approach to detecting fraud and managing the fraudulent claims process through investigation, prosecution and settlement.
“Harvard Pilgrim is committed to providing value to our members, and fraud prevention is critical to keeping premiums reasonable” said Eric H. Schultz, president and CEO of Harvard Pilgrim Health Care. “We are pleased to be working with LexisNexis to enhance our capabilities throughout the claims lifecycle.”
Intelligent Investigator is a highly engineered fraud-detection system that pinpoints patterns of suspicious behavior across all health care claim types, including medical, facility, pharmaceutical and dental. It allows users to mine vast sources of data, prioritize cases and trace leads by provider, member/patient, transaction and related data.
Trail Tracker, which is integrated with Intelligent Investigator, enables staff to plan a course of action for each investigation, identify activities needed, document investigations, create reminders and manage records. It allows for tracking cases by status, tracking referral tips, assigning claims to specific departments for review, assigning cases to investigators and managing investigator workloads. SIU management can also measure investigator progress on files, trace recoveries, calculate savings and create reports on unit activities.
“LexisNexis looks forward to working with Harvard Pilgrim as the organization remains one of the nation’s top private health plans because it is constantly ahead of the curve in customer service – and now clearly in the area of fraud detection and prevention,” said Lee Rivas, CEO, Public Sector and Health Care, LexisNexis.
About LexisNexis Risk Solutions
At LexisNexis Risk Solutions, we believe in the power of data and advanced analytics for better risk management. With over 40 years of expertise, we are the trusted data analytics provider for organizations seeking actionable insights to manage risks and improve results while upholding the highest standards for security and privacy. Headquartered in metro Atlanta USA, LexisNexis Risk Solutions serves customers in more than 100 countries and is part of RELX Group, a global provider of information and analytics for professional and business customers across industries. For more information, please visit www.risk.lexisnexis.com.