Data Mining Snares Health Insurance Fraud

As Medicare searches for ways to head off fraud, private payers are starting to embrace predictive modeling in their own quest to stamp out insurance fraud before claims are paid. "I think the big move on the payer side is to pre-pay," according to Bill Fox, senior director of LexisNexis Health Care, a year-and-a-half-old division of online information giant LexisNexis, a subsidiary of Reed Elsevier. That means payers are trying to examine claims before the money goes out the door. "Virtually every big payer we talk to is thinking about it," Fox told InformationWeek Healthcare.

LexisNexis is among those joining the movement to detect fraud with advanced data mining by building analytics and risk-management capabilities into its vast data platforms. The company has built databases on 250 million people in the U.S., culled from 35 billion public records, and now is applying its analytics capabilities to health insurance...