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New Fraud Prevention Study Results to be Released by LexisNexis Risk Solutions and National Health Care Anti-Fraud Association at the NHCAA Anti-Fraud Expo

Study sheds light on how external derogatory data help government and private payers prevent provider fraud


ATLANTA – – Through the National Health Care Anti-Fraud Association (NHCAA) database >SIRIS (Special Investigative Resource and Intelligence System), hosted by LexisNexis® Risk Solutions, NHCAA brings insights to the market on how to curb health care provider fraud. Now, the results of a joint research study between LexisNexis Health Care and the NHCAA provide a new vantage point from which NHCAA members can view potential fraud, waste and abuse (FWA). The study results will be announced at the >NHCAA Anti-Fraud Expo, November 15-17, Atlanta, GA.

SIRIS is a contributory database that allows NHCAA members to submit, track, monitor and share information related to potential provider fraud and associated investigations. The new research study assessed the value of adding external provider derogatory data to SIRIS and determined the following:

  • Incorporation of external derogatory provider data into SIRIS can expose providers that possess strong indicators of fraud.
  • Fraud data from different industries can provide alerts of potential fraud earlier than data from within a single market

“The key learning from the study was that incorporating public records such as bankruptcies, liens and judgements, medical license expirations and criminal records all can shine additional light on health care fraud,” said Cynthia Lucas, Senior Director of Anti-Fraud Initiatives, NHCAA. “When we add the ability to leverage interest across multiple industries to identify suspicious subjects, we become much better equipped to catch newer, more sophisticated fraud schemes. Our joint research study with LexisNexis Health Care reveals new ways to determine activities and signals that are highly predictive of fraud and enable our members to address potential fraud earlier.”

Specifically for the study, SIRIS providers were analyzed using LexisNexis Health Care data and analytics to see what derogatory data was returned and if that data applied to the SIRIS records in a meaningful way. LexisNexis Health Care applied three additional layers of data in the study:

  • Provider-centric data such as licenses, sanctions, National Provider Identifier and Drug Enforcement Administration information;
  • Non-health indicators such as criminal, sex offender, deceased records, bankruptcy liens and judgements; and  
  • Fraud inquiries from finance, insurance and government markets from the LexisNexis® Fraud Defense Network (FDN), a cross-industry initiative offering resources and actionable intelligence to connect the dots between different industries to improve fraud mitigation and prevention efforts.

For example, in the study, the FDN detected 124 SIRIS providers at high risk for fraud from outside of health care, including one provider investigated for financial services fraud three times and insurance fraud one time the year before being added to SIRIS. The study also found several examples of bankruptcies filed the year before these providers were added to SIRIS investigations for services not provided and up-coding.

“When payers have data on licensing expirations and deceased records, they can withhold payment for further investigation of fraud,” said Mark Isbitts, Director, Payment Protection, LexisNexis Health Care. “Other types of data, like bankruptcies or past fraud inquiries within other industries, help insurers identify indicators of potential fraud.”

The ability to predict the likelihood that a provider has committed or may commit fraud in the future enables insurers to prioritize providers based on risk and optimize resource allocation for monitoring, investigating and preventing FWA.

Isbitts will discuss how data insights can help prevent fraud in his presentation, “The New Menace: FWA on the Marketplace Exchange & Organized Crime” on Thursday, November 17th at 10:30 a.m. at the NHCAA Annual Training Conference, Hanover DE, Exhibit Level.

About LexisNexis Risk Solutions
LexisNexis® Risk Solutions harnesses the power of data, sophisticated analytics platforms and technology solutions to provide insights that help businesses across multiple industries 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.

Founded in 1985, the National Health Care Anti-Fraud Association is the leading national organization focused exclusively on the fight against health care fraud. Members comprise more than 100 private health insurers and those public-sector law enforcement and regulatory agencies having jurisdiction over health care fraud committed against both private payers and public programs[No text in field]
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