Case Studies Lovelace Health Plan Looks to Make Significant Recoveries From Fraud, Waste and Abuse Activities with LexisNexis® Anti-Fraud Services and Technology

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	Lovelace Health Plan Looks to Make Significant Recoveries From Fraud, Waste and Abuse Activities with LexisNexis® Anti-Fraud Services and Technology

Lovelace Health Plan Looks to Make Significant Recoveries From Fraud, Waste and Abuse Activities with LexisNexis® Anti-Fraud Services and Technology

Technology Category	Analytics & Modeling - Predictive Analytics Application Infrastructure & Middleware - Data Exchange & Integration Functional Applications - Enterprise Resource Planning Systems (ERP)
Applicable Industries	Healthcare & Hospitals
Applicable Functions	Business Operation Quality Assurance
Use Cases	Fraud Detection Regulatory Compliance Monitoring Remote Asset Management
Services	System Integration Training
Challenge	To meet the rising threat of health care fraud, Lovelace sought a robust solution to maximize its detection abilities. Read More
About Customer	The Albuquerque-based Lovelace Health Plan provides insurance coverage for more than 210,000 members in communities across New Mexico. It is part of the Lovelace Health System, which includes six hospitals. Lovelace offers a broad range of health plan options and programs, as well as coverage with a continually expanding network of providers and health care centers. Read More
Solution	The SIU Compliance Officer, Paul Peoples, teamed up with LexisNexis to understand how to optimize the use of the company’s Virtual SIU™ investigative services and Intelligent Investigator™ advanced fraud detection system. Virtual SIU gathers, analyzes and manages fraud-related data. It streamlines complex management processes and ensures SIU activities are compliant with regulatory guidelines. Fully scalable, this service is designed to work as a completely outsourced solution or to augment overburdened internal SIU units. Built exclusively for health care, Intelligent Investigator pinpoints patterns of suspicious behavior across all health care claim types, including medical, facility, pharmaceutical and dental. With its easy-to-use interface, Intelligent Investigator effortlessly walks users at all levels through potential fraudulent cases. Taking advantage of the customizable education platform and training offered by LexisNexis, Lovelace completed a two-day program in which Peoples and other key staff members were familiarized with the solutions’ use and capabilities. Read More Log in to view content
Contents

Technology Category

Analytics & Modeling - Predictive Analytics

Application Infrastructure & Middleware - Data Exchange & Integration

Functional Applications - Enterprise Resource Planning Systems (ERP)

Applicable Industries

Healthcare & Hospitals

Applicable Functions

Business Operation

Quality Assurance

Use Cases

Fraud Detection

Regulatory Compliance Monitoring

Remote Asset Management

Services

System Integration

Training

Challenge

To meet the rising threat of health care fraud, Lovelace sought a robust solution to maximize its detection abilities.

About Customer

The Albuquerque-based Lovelace Health Plan provides insurance coverage for more than 210,000 members in communities across New Mexico. It is part of the Lovelace Health System, which includes six hospitals. Lovelace offers a broad range of health plan options and programs, as well as coverage with a continually expanding network of providers and health care centers.

Solution

The SIU Compliance Officer, Paul Peoples, teamed up with LexisNexis to understand how to optimize the use of the company’s Virtual SIU™ investigative services and Intelligent Investigator™ advanced fraud detection system. Virtual SIU gathers, analyzes and manages fraud-related data. It streamlines complex management processes and ensures SIU activities are compliant with regulatory guidelines. Fully scalable, this service is designed to work as a completely outsourced solution or to augment overburdened internal SIU units. Built exclusively for health care, Intelligent Investigator pinpoints patterns of suspicious behavior across all health care claim types, including medical, facility, pharmaceutical and dental. With its easy-to-use interface, Intelligent Investigator effortlessly walks users at all levels through potential fraudulent cases. Taking advantage of the customizable education platform and training offered by LexisNexis, Lovelace completed a two-day program in which Peoples and other key staff members were familiarized with the solutions’ use and capabilities.

Impact #1	Initially, the Virtual SIU was charged with looking at Evaluation and Management (E/M) Coding to uncover outliers among various procedures. The unit found a large number of potentially fraudulent activities quickly, Peoples said, adding that LexisNexis began sending 'great provider utilization reports.'
Impact #2	Among the findings were a number of potentially 'egregious billers,' and LexisNexis helped with the probe review of sample cases to validate the identified questionable claims, Peoples said.
Impact #3	In addition to setting the stage for significant recoveries from possible fraudulent and abusive activities, the information acquired also has been helpful in educating providers who have made errors with no intent to defraud. In such cases, the Compliance Officer said, the Plan can alert the provider, fostering a positive working relationship.

Impact #1

Initially, the Virtual SIU was charged with looking at Evaluation and Management (E/M) Coding to uncover outliers among various procedures. The unit found a large number of potentially fraudulent activities quickly, Peoples said, adding that LexisNexis began sending 'great provider utilization reports.'

Impact #2

Among the findings were a number of potentially 'egregious billers,' and LexisNexis helped with the probe review of sample cases to validate the identified questionable claims, Peoples said.

Impact #3

In addition to setting the stage for significant recoveries from possible fraudulent and abusive activities, the information acquired also has been helpful in educating providers who have made errors with no intent to defraud. In such cases, the Compliance Officer said, the Plan can alert the provider, fostering a positive working relationship.

Benefit #1	Lovelace Health Plan provides insurance coverage for more than 210,000 members.
Benefit #2	The company completed a two-day training program to familiarize key staff members with the solutions’ use and capabilities.

Benefit #1

Lovelace Health Plan provides insurance coverage for more than 210,000 members.

Benefit #2

The company completed a two-day training program to familiarize key staff members with the solutions’ use and capabilities.

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Overview

Lovelace Health Plan Looks to Make Significant Recoveries From Fraud, Waste and Abuse Activities with LexisNexis® Anti-Fraud Services and Technology

Operational Impact

Quantitative Benefit