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
LexisNexis® Risk Solutions includes seven brands that span multiple industries and sectors. We harness the power of data, sophisticated analytics platforms and technology solutions to provide insights that help businesses and governmental entities reduce risk and improve decisions to benefit people around the globe. Headquartered in metro Atlanta, Georgia, we have offices throughout the world and are part of RELX (LSE: REL/NYSE: RELX), a global provider of information-based analytics and decision tools for professional and business customers. For more information, please visit LexisNexis Risk Solutions and RELX.