Case Study: Leading Midwestern Managed Care Health Plan achieves rapid detection of $2M prescribing fraud with LexisNexis Risk Solutions

Leading Healthcare Provider - Customer Case Study

A Midwestern non-profit managed care company serving more than 1.5 million members detected an unusual surge in prescriptions of Nuedexta® from a single neurologist. Although prior authorizations and office-billed services appeared compliant, the doctor’s prescribing volume and diagnosis patterns stood out, and fragmented data across multiple silos made it difficult for the plan’s Special Investigations Unit to quantify the problem quickly.

The plan deployed LexisNexis Intelligent Investigator to aggregate and analyze medical and pharmacy claims, run peer-to-peer comparisons, and refine prior-authorization rules. The tool revealed the doctor accounted for 70% of all Nuedexta prescriptions (2,564 fills over 30 months), exposed missing neurological diagnoses in many records, supported regulatory referral and license suspension, and helped the plan halt over $2 million in questionable prescription claims while accelerating investigations.