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.

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.

Benefits:

  • 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

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:

  • Leverages Provider of Interest Score, a powerful predictive modeling tool that utilizes statistical techniques to identify indicators of fraud, waste and abuse.
  • Leverages 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.
  • Incorporates 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
  • Robust ad-hoc reporting system

Contact Us

For more information about our solutions call 800.869.0751 or contact us online

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.

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Did you know?

The National Health Care Anti-Fraud Association estimates that between 3-10 percent of what Americans spend annually on health care is lost to fraud and abuse.