Intelligent Investigator™
Pinpoint fraud with confidence
LexisNexis® Intelligent Investigator™ is an advanced fraud, waste and abuse detection and data mining system that leverages sophisticated rules-based analytics to identify and prioritize the cases that are potentially most likely to achieve the best 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.
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Benefits
LexisNexis Intelligent Investigator™ is a rules-based overpayment detection system that pinpoints suspicious behavior across all health care claim types, including medical, facility, pharmaceutical and dental. Intelligent Investigator’s easy-to-use interface allows users to trace leads by provider, member/patient and transaction. Its advanced drill-down feature lets users drill all the way down to a comprehensive Patient History snapshot. Diagnosis, physician visits, inpatient stays and prescription usage are presented in this view.
- Increased understanding of provider billing practices
- Easier compilation of data necessary to more efficiently prepare for a case
- 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.
- Enablement of non-IT experts to target specific providers and claims based on incomplete data
Features
LexisNexis® Intelligent Investigator™ advanced drill-down feature allows users to trace leads by provider, member/patient, transaction and other related data with ease. Special screens have been built in to assist investigators in identifying providers or claims based on partial information or tips off fraud hotlines. The user-friendly system also supports usage by non-investigative departments such as provider relations, medical directors, finance and audit among others.
Features include:
- Provider of Interest Score, a powerful predictive modeling tool that utilizes statistical techniques to identify indicators of 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.
- Public records data
- Flexible rules-based structure, with rules that can be easily modified by users as new schemes are detected
- Promotes a holistic view of patient, claim and pharmacy data
- Ad-hoc reporting system
