Intelligent Investigator™

Surface new healthcare fraud leads, facilitate investigations and build cases with confidence.

Stem the rising tide of healthcare fraud.

Healthcare fraud schemes continue to become more complex. Organized crime, as well as complex billing and referral schemes, make finding healthcare fraud a challenge for even the savviest investigator. Special Investigations Units (SIUs), Program Integrity and Medicaid Fraud Control Units often do not have the necessary resources to investigate all claims, which hinders their ability to identify and research fraud schemes in a proactive and efficient manner. This allows healthcare fraud schemes to flourish, costing the United States healthcare system billions each year.

Intelligent Investigator is quick, intuitive, and comprehensive approach to healthcare fraud detection.

LexisNexis® Intelligent Investigator™ is an advanced healthcare fraud, waste and abuse detection and investigation tool that uses sophisticated rules-based analytics to identify and prioritize the cases that are potentially most likely to achieve the best recovery results.

Results are delivered through a powerful web-based portal that provides dashboard summaries of domain specific information through graphs, bar, and pie charts. Special screens have been built in to assist investigators in identifying fraudulent providers or claims based on partial information from tips and leads.

Benefits to Healthcare Payers

LexisNexis Intelligent Investigator™ pinpoints suspicious behavior across all healthcare claim types, including medical, facility, pharmaceutical and dental. The easy-to-use interface allows users to trace leads by provider, member/patient and transaction.

Score, Prioritize, and Monitor Provider Trends
  • Increase understanding of provider billing practices.
  • Make comparisons within specialty peer groups, to help you understand who has behaviors that stand out and may be indicative of healthcare fraud, waste and abuse.
  • Use a prioritized workflow that looks at both the provider and claims levels to reduce the number of false positives and that provides “suspicion scores” with transparent explanations to prioritize cases.

Research Claims Across Systems in a Single View
  • Easier compilation of data necessary to more efficiently prepare for a case.
  • Deploy hundreds of rules covering medical, dental, pharmacy – taken from sources like CCI, medical societies and also from our experience in the industry.
  • Use advanced drill-down feature lets users to see a comprehensive Patient History snapshot. This includes diagnosis, physician visits, inpatient stays and prescription usage.
User-friendly Interface for SIU and other stakeholders
  • Enablement of non-IT experts to target specific providers and claims based on incomplete data

Intelligent Investigator's Key Features

  • Provider of Interest Score, a powerful predictive modeling tool that utilizes statistical techniques to identify indicators of healthcare fraud, waste and abuse.
  • Composite Lead Indicator (CLI), a proprietary indexing tool that prioritizes the potential savings and recovery probability of each lead in order to establish the recommended index order.
  • Insights derived from combining customer data with LexisNexis Public Record information.
  • Flexible rules-based structure that can be easily modified by users as new schemes are detected.
  • Provides a holistic view of patient, claim and pharmacy data.
  • Comprehensive dashboard as well as ad-hoc reporting.

Get it now: For more information about Intelligent Investigator, please call 866.396.7703.


Detect and Prevent Fraud with Intelligent Investigator™

Case Study

Healthcare Billing Fraud Detection

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LexisNexis® Intelligent Investigator™ does not constitute a “consumer report” as that term is defined in the federal Fair Credit Reporting Act, 15 USC 1681 et seq.(FCRA). Accordingly, LexisNexis Intelligent Investigator may not be used in whole or in part as a factor in determining eligibility for credit, insurance, employment or another permissible purpose under the FCRA. Due to the nature of the origin of public record information, the public records and commercially available data sources used in reports may contain errors. Source data is sometimes reported or entered inaccurately, processed poorly or incorrectly, and is generally not free from defect. This product or service aggregates and reports data, as provided by the public records and commercially available data sources, and is not the source of the data, nor is it a comprehensive compilation of the data. Before relying on any data, it should be independently verified.