Large Health Plan Finds Provider Fraud Using Relationship Mapping

Needing a more robust fraud detection solution for their Special Investigations Units (SIU), a large health plan turned to LexisNexis’ Relationship Mapping solution to uncover potential provider fraud at the address level. Using vast data resources and social network analytics in the Relationship Mapping Suspect Address module, investigators were able to uncover suspected healthcare provider fraud that occurred at suspect addresses. This analysis went beyond claims data, integrating various types of records to show a complete picture of providers and addresses. This prioritized investigations and leads, showing outliers in the data, indicative of potential provider fraud.

The intricate web of provider fraud is difficult to see without a solution and data that shows relatives, associates, businesses, other providers and pharmacists. Most healthcare fraud solutions use medical claims data only to uncover potential fraudulent billing. Relationship Mapping leverages vast resources of outside data and proprietary linking capabilities. This health plan, coupled with the advanced analytics that clearly showed the hidden connections, was able to spend less time doing research and more time pursuing provider fraud leads that offered the greatest potential return on investment.

This health plan was able to quickly uncover provider fraud and situations that merited more scrutiny by their Special Investigations Unit. For example, investigators found providers prescribing medications with revoked licenses, providers who were unlikely to write certain prescriptions and providers who were writing fraudulent prescriptions for themselves. This is just a few of the examples of how Relationship Mapping found hidden relationships to quickly surface potential provider fraud.

Download our newest case study today to read how this health plan integrated Relationship Mapping into their investigative workflow to detect and investigate potential provider fraud.