Healthcare Billing Fraud Detection Case Studies

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LexisNexis® Intelligent Investigator® helps our customers uncover fraudulent overpayments, find trends in coding discrepancies, conduct CMS audits and centralizes investigative data.

Complex healthcare billing fraud schemes are often difficult to detect because of the mountains of siloed data in disparate systems. Connecting the dots, using tools like Intelligent Investigator and Trail Tracker, can help health plans quickly see suspicious activity, like fraudulent prescribing patterns, trends in coding discrepancies and overpayments that would have gone undetected.  

The benefits to customers go beyond detecting potential fraudulent schemes. Looking across claims to detect potential vulnerabilities is another key benefit of Intelligent Investigator. By integrating previously disparate data into the solution, health plans can address those potential vulnerabilities through medical policies and enhanced provider education.  Learn how one health plan used these insights to create rules to prevent future wrongful payments. 

These two case studies will detail how two different health plans implemented and used LexisNexis® Intelligent Investigator™  to analyze medical and pharmacy claims, turning mountains of data into the precise intelligence they needed to uncover fraud. LexisNexis Intelligent Investigator showed both plans the extent of the problem—so they could act immediately to fix it—by pinpointing suspicious behavior across all claim types. In addition, Trail Tracker helped them build documents and manage fraudulent claims from investigation through prosecution and settlement. Both tools empowered the SIU to manage cases more efficiently saving valuable staff time.
Read about how one Special Investigations Unit implemented and integrated these solutions in their workflow. Download this case study to read why one plan considers LexisNexis Intelligent Investigator an “invaluable” tools to quickly find, stop and mitigate fraudulent billing activity.
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Download our second case study on the right to see the full value of both Intelligent Investigator and Trailer Tracker used together to mitigate and detect healthcare fraud.

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