Shipi Kankane Prashanth Nakirekommula

 Applying analytics and risk- management capabilities to health insurance through LexisNexis data platforms.  Databases on 250 million people in the U.S. sampled from 35 billion public records.  Data analysis using its supercomputer platform, which is built on top of open-source platform (High Performance Computing Cluster)  Allows for fast queries of "massive amounts of big data.”

 Earlier Situation: Pay and Chase model - insufficient and unsustainable  Current Solution: ◦ Proactive - identifies and mitigates fraud throughout business workflow ◦ Identify fraud patterns and risk indicators as they emerge.

Predictive Modeling  Metrics  Scores  Detect inherent risks Traditional Method:  Single claim  Claim Edit  No pattern identification

Definition: Predictive Analysis translates data into descriptive or predictive models using various forms of statistical analysis techniques Classification and Regression Trees (CART) Chi Square Automatic Interaction Detection (CHAID). Linear and logistic regression models Analysis of variance Discriminate analysis.

 Early detection of fraud, waste and abuse  Prioritized results with fewer false positives  Alerts concerning adverse changes in the status of individuals or entities  Consistent control over risk, quality and costs using automated screening and monitoring  Lower claims losses, better financial management than traditional “post-payment only” methods

 Understand your data – Patient demographics, Hospital Information etc.  Determine your population makeup – Sampling issues, representativeness  Discover relationships in your data – Relations between various variables identified in Step 1  Build a model – Rule induction and based on step 3  Use model against actual records – Test for predictive power  Identify anomalies – Outliers

 SAS datamining tool – tree based model, multianalytics approach  IBM SPSS modeler – rule induction

Neil Versel, Data Mining Snares Health Insurance Fraud, InformationWeek, November 15,2011 LexisNexis® Health Care Solutions for Fraud, Waste and Abuse Prevention retrieved from lexisnexis.com HPCC Systems ( IBM Software Business Analytics, IBM Corporation, May 2011