Achieving Member, Financial and Operational Health: The next generation of fraud, waste and abuse detection, prevention and recovery

December 7, 2012
1:00 pm - 2:00 pm EST

Presented by LexisNexis 

Today, more than ever before, health plans are facing increasing pressure to protect the financial interests of their members. They must balance the expectation that they facilitate their members receiving the right care, at the right time, in the right setting from the highest quality providers at the most competitive rate of reimbursement. Additionally, health plans need to ensure that only legitimately eligible claims are being paid and that the health care partners providing care to their members are not engaging in fraudulent or abusive billing patterns. 

Managing these competing priorities requires payers to make the most of limited resources.  Of top priority is the need to ensure that employees’ attention is focused on those things that will provide the greatest return on the investment of their time and efforts.  To achieve this, plans must effectively leverage external resources to compliment work being done in-house, and, perhaps most importantly, understand that success requires employing solutions that recognize the interconnectivity between different business units. 

The next generation of fraud, waste and abuse solutions speaks to the industry’s changing needs. Attendees will learn:

  1. The value of vetting providers in your network through a comprehensive integrity check at the time of enrollment and on an on-going basis.
  1. How effectively combining traditional rules-based claims edits with well-developed predictive modeling capabilities reduces the opportunity for ineligible claims to make it through your system.
  1. Ways to combine public data with information contained within your own records to identify potentially high-risk member and provider attributes that would otherwise go undetected.

List of Speakers: 

Ken Cunningham
VP, Analytics
LexisNexis Risk Solutions

Ken Cunningham is Vice President, Insurance Claims Analytics, for the risk solutions business of LexisNexis®. He is responsible for overseeing the development of analytics to help insurance carriers improve their claims payment processes, including avoiding fraud and subrogation losses, among other problems.

He joined LexisNexis in 2005 from Magnify, where he worked alongside the founder to implement business strategies for advanced predictive modeling. In this capacity, he worked in credit card fraud identification, e-mail targeting, and insurance carriers. With more than 30 years business and risk solutions experience, Cunningham has also worked as Senior Vice President for Bank of America, Managing Director at Continental and Managing Director at Mitsubishi Financial International.

Cunningham earned his bachelor’s degree in economics from Colorado College.


The content presented in this webinar is solely attributable to the speaker and does not represent an endorsement by America's Health Insurance Plans (AHIP) of the accuracy of the information presented in the audio conference or any opinion expressed by the speaker.