Case Study: Ivy Health achieves improved fraud detection and higher recoveries with LexisNexis Risk Solutions' Relationship Mapping

How one health plan is improving its ability to detect fraud and increase recoveries

Ivy Health (a pseudonym) is a multi-state private health plan seeking to reduce fraud, waste and abuse without adding headcount. Its Special Investigations Unit was limited by manual, provider-by-provider reviews and needed better tools to detect collusive schemes and prioritize high-risk cases more efficiently.

Working with LexisNexis Risk Solutions, Ivy Health deployed Relationship Mapping’s Suspect Address analytics to link addresses, providers, patients and associates using external data and social‑network analysis, producing address and provider risk scores to highlight outliers. The tool sped investigations, uncovered 30 leads with a $58M net value (examples included a revoked-license prescriber tied to 394 paid scripts >$250K and unusual prescribing by pathologists totaling ~$230K), and delivered projected recoveries—conservatively $323K in 2018 at a 3% recovery rate and $1.7M across three years—while reducing manual research and increasing recoveries.

Ivy Health