LexisNexis® Provider of Interest Score supports investigators by identifying providers with irregular diagnosis, treatment and billings patterns, highlighting data points where the provider is an outlier from his/her peers, and augmenting data on identified providers with public records such as financial, criminal and medical-sanction derogatory information.
Predictive modeling, as employed by LexisNexis® Provider of Interest Score, utilizes statistical techniques to identify combinations of factors that should be analyzed as fraud, waste and abuse indicators. Scoring then prioritizes results, focusing on areas that have the highest probability of fraud, waste and abuse.
- Focus efforts in the right places, with false positives reduced by detecting fraud, waste and abuse at the provider level, rather than at an individual claim level
- Identify patterns of aberrant behavior in providers and uncover indications of emerging fraudulent schemes
- Optimize claims operations and lower operational costs by accelerating needed investigations and fast-tracking valid claims
LexisNexis® Provider of Interest Score is customized for each organization, taking into account their individual policies and available resources. Models can be based on previously identified fraud, waste and abuse or built without identified problems. Custom models can also address factors such as differences in diagnosis and treatment patterns by geography.
- Adherence to Service-Oriented Architecture standards to minimize the necessity for IT involvement
- Integration with LexisNexis® Intelligent Investigator™
- A three-digit score from 100 to 999, with the highest scores equating to higher indications of potential for fraud, waste and abuse, prevention and recovery