Health Care

Fraud, Waste and Abuse

According to the National Health Care Anti-Fraud Association, fraud accounts for $70 to $234 billion a year—about $190 to $640 million per day. Health care payers are challenged with meeting prompt-pay laws and meeting Medical Loss Ratio requirements with limited resources.

The approach to detecting, identifying and preventing fraud, waste and abuse is shifting and becoming a priority to departments beyond Special Investigation Units (SIU). LexisNexis applies distinctive capabilities to help payers reduce wasteful spending and improve efficiency, while evolving their fraud, waste and abuse programs. Our suite of pre- and post- pay tools to detect new patterns, uncover new patterns and put up blocks for emerging patters of fraud, waste and abuse in both the pre and post pay environment. Leveraging more than 37 billion public records from over 10,000 data sources, the industry's leading source of provider and a powerful computing platform and intuitive user interfaces LexisNexis delivers:

  • A 360 degree view of member, provider and claim for deeper dive into data
  • Prioritized leads thru provider level scoring
  • Ad-hoc and embedded reporting, with rules development at the desktop
  • Transparency into causes of suspicion

In addition to our workflow solutions, LexisNexis offers supplemental SIU services to augment and support internal investigative efforts. Our Virtual SIU team helps triage investigations, conduct medical records review and more.

LexisNexis®, a Premier Supporting Member of the National Health Care Anti-Fraud Association and the Association of Health Insurance Plans (AHIP) Select Member, offers a multi-layered enterprise approach to fraud, waste, and abuse identification and prevention.

  1. The Real Cost of Health Care Fraud - And New Ways to Fight It
    Stopping the Flow of Health Care Fraud with Technology, Data and Analytics
  2. Key Factors for Payers in Fraud & Abuse Prevention
    Protect against fraud and abuse with a multi-layered approach to claims management
  3. Public Records for Health Care
    Reduce exposure to claims fraud with integration of public records
  4. Bending the Cost Curve: Analytic Driven Enterprise Fraud Control
    Three percent, or $60 billion, of all health care spending is lost to fraud.
  5. The Rise of Organized Crime in Health Care: Social Network Analytics Uncover Hidden and Complex Fraud Schemes
    Experience the power of data, linking and analytics

Next Step

To learn more about our Fraud, Waste and Abuse solutions or to receive pricing information:
Call us at 866.396.7703
Fill out our contact form.

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