Harvard Pilgrim Health Care Taps LexisNexis® to Fight Fraud, Waste and Abuse


ConnellyWorksMary Alice Johnson, 571-323-2585, ext. 2140

LexisNexis Risk Solutions today announced the company has been selected by – the number one private health plan in America for the last 10 years according to the National Committee for Quality Assurance (NCQA)* – to help detect, investigate and recover fraudulent claims. LexisNexis Intelligent Investigator and Trail Tracker solutions provide Harvard Pilgrim’s Special Investigative Unit (SIU) an enterprise approach to detecting fraud and managing the fraudulent claims process through investigation, prosecution and settlement.

“Harvard Pilgrim is committed to providing value to our members, and fraud prevention is critical to keeping premiums reasonable,” said Eric H. Schultz, president and CEO of Harvard Pilgrim Health Care. “We are pleased to be working with LexisNexis to enhance our capabilities throughout the claims lifecycle.”

Intelligent Investigator is a highly engineered fraud-detection system that pinpoints patterns of suspicious behavior across all health care claim types, including medical, facility, pharmaceutical and dental. It allows users to mine vast sources of data, prioritize cases and trace leads by provider, member/patient, transaction and related data.

Trail Tracker, which is integrated with Intelligent Investigator, enables staff to plan a course of action for each investigation, identify activities needed, document investigations, create reminders and manage records. It allows for tracking cases by status, tracking referral tips, assigning claims to specific departments for review, assigning cases to investigators and managing investigator workloads. SIU management can also measure investigator progress on files, trace recoveries, calculate savings and create reports on unit activities.

“LexisNexis looks forward to working with Harvard Pilgrim as the organization remains the nation’s number one private health plan because it is constantly ahead of the curve in customer service – and now clearly in the area of fraud detection and prevention,” said Lee Rivas, CEO, Public Sector and Health Care, LexisNexis.

Harvard Pilgrim Health Care is a not-for-profit health plan serving more than one million members in New England. Founded in 1969, the health plan has built its reputation on pragmatic innovation with a goal of lowering costs, improving care and enhancing the overall member experience. Harvard Pilgrim is known for its excellent clinical programs, customer service, health improvement strategies and innovative tools that offer consumers greater transparency and empower them to make better decisions about their health care.

Harvard Pilgrim is the #1 private health plan in America again according to an annual ranking of the nation’s best health plans by the National Committee for Quality Assurance (NCQA). Harvard Pilgrim is

* NCQA’s Private Health Insurance Plan Rankings, 2011-14, HMO/POSNCQA’s Health Insurance Plan Rankings 2010-11 – Private./NCQA America’s Best Health Insurance Plans 2005-2009 (annual). America’s Best Health Insurance Plans is a trademark of . NCQA The State of Health Care Quality 2004. Harvard Pilgrim Health Care of New England, Harvard Pilgrim’s New Hampshire affiliate, is the top-ranked private health plan in New Hampshire and the 9 highest-ranked private health plan in America.

LexisNexis Risk Solutions () is a leader in providing essential information that helps customers across all industries and government assess, predict and manage risk. Combining cutting-edge technology, unique data and advanced analytics, LexisNexis Risk Solutions provides products and services that address evolving client needs in the risk sector while upholding the highest standards of security and privacy. LexisNexis Risk Solutions is part of Reed Elsevier, a world leading provider of professional information solutions.

Our health care solutions assist payers, providers and integrators with ensuring appropriate access to health care data and programs, enhancing disease management contact ratios, improving operational processes, and proactively combating fraud, waste and abuse across the continuum.