EEMCS EPrints Service
van Capelleveen, G.C and Poel, M. and Müller, R.M. and Thornton, D. and van Hillegersberg, J. (2016) Outlier Detection in Healthcare Fraud: A case study in the Medicaid dental domain. International Journal of Accounting Information Systems, 21. pp. 18-31. ISSN 1467-0895 ISBN 978-989-758-028-4 *** ISI Impact 1,128 ***
This is the latest version of this eprint.
Full text available as:
Official URL: http://dx.doi.org/10.1016/j.accinf.2016.04.001
Health care insurance fraud is a pressing problem, causing substantial and increasing costs in medical insurance programs. Due to large amounts of claims submitted, estimated at 5 billion per day, review of individual claims or providers is a difficult task. This encourages the employment of automated pre-payment controls and better post-payment decision support tools to enable subject matter expert analysis. This paper presents how to apply unsupervised outlier techniques at post-payment stage to detect fraudulent patterns of received insurance claims. A special emphasis in this paper is put on the system architecture, the metrics designed for outlier detection and the flagging of suspicious providers which may support the fraud experts in evaluating providers and reveal fraud. The algorithms were tested on Medicaid data encompassing 650,000 health-care claims and 369 dentists of one state. Two health care fraud experts evaluated flagged cases and concluded that 12 of the top 17 providers (71%) submitted suspicious claim patterns and should be referred to officials for further investigation. The remaining 5 providers (29%) could be considered mis-classifications as their patterns could be explained by special characteristics of the provider. Selecting top flagged providers is demonstrated to be a valuable as an targeting method, and individual provider analysis revealed some cases of potential fraud. The study concludes that, through outlier detection, new patterns of potential fraud can be identified and possibly utilized in future automated detection mechanisms.
Available Versions of this Item
Export this item as:
To request a copy of the PDF please email us request copy
To correct this item please ask your editor
Repository Staff Only: edit this item