LexisNexis Intelligent Investigator Reviews & Product Details

LexisNexis® Intelligent Investigator™ is an advanced post-payment analysis tool designed to detect and prioritize cases of fraud, waste, and abuse within healthcare claims. By leveraging sophisticated rules-based analytics, it identifies aberrant patterns indicative of emerging fraud schemes, enabling investigative teams to focus on the most promising leads. Key Features and Functionality: - Prioritized Workflow: Utilizes a Composite Lead Indicator (CLI) to rank leads based on potential savings and recovery probability, ensuring investigators address the most impactful cases first. - Provider of Interest Score (POI): Employs models to detect providers with irregular diagnosis, treatment, and billing patterns, highlighting outliers and augmenting data with public records such as financial, criminal, and medical sanction information. - Comprehensive Data Integration: Aggregates data from multiple sources, including licensure and certifications, to create a unified view of providers and claims. - Advanced Analytics: Applies healthcare-specific rules and predictive analytics to uncover non-obvious connections and detect emerging fraud schemes. - User-Friendly Interface: Features a web-based portal with dashboard summaries, graphs, and charts, facilitating easy navigation and interpretation of data. - Customizable Reporting: Offers hundreds of pre-formatted reports and ad-hoc reporting capabilities, allowing users to generate and prioritize cases without burdening internal IT departments. - Integration with Trail Tracker™: Seamlessly connects with LexisNexis' fraud recovery and case tracking system, reducing the time and effort required to build solid cases for full-scale investigations. Primary Value and User Solutions: Intelligent Investigator transforms the traditional reactive approach to fraud detection into a proactive, efficient process. By automating the identification and prioritization of suspicious claims, it reduces manual effort, minimizes false positives, and accelerates the investigative workflow. This leads to significant cost savings, improved program integrity, and enhanced ability to recover funds lost to fraudulent activities. The system's comprehensive data integration and advanced analytics provide investigators with actionable intelligence, enabling them to make informed decisions and effectively combat fraud, waste, and abuse in healthcare claims.