Electronic fraud detection in the U.S. Medicaid Healthcare Program: lessons learned from other industries

It is estimated that between $600 and$850 billion annually is lost to fraud, waste, and abuse in the US healthcare system,with $125 to$175 billion of this due to fraudulent activity (Kelley 2009). Medicaid, a state-run, federally-matchedgovernment program which accounts for roughly one-quarter of all healthcare expenses in the US, has been particularlysusceptible targets for fraud in recent years. With escalating overall healthcare costs, payers, especially government-runprograms, must seek savings throughout the system to maintain reasonable quality of care standards. As such, the need foreffective fraud detection and prevention is critical. Electronic fraud detection systems are widely used in the insurance,telecommunications, and financial sectors. What lessons can be learned from these efforts and applied to improve frauddetection in the Medicaid health care program? In this paper, we conduct a systematic literature study to analyze theapplicability of existing electronic fraud detection techniques in similar industries to the US Medicaid program

A comparative analysis of decision trees vis-a-vis other computational data mining techniques in automotive insurance fraud detection

The development and application of computational data mining techniques in financial fraud detection and business failure prediction has become a popular cross-disciplinary research area in recent times involving financial economists, forensic accountants and computational modellers. Some of the computational techniques popularly used in the context of - financial fraud detection and business failure prediction can also be effectively applied in the detection of fraudulent insurance claims and therefore, can be of immense practical value to the insurance industry. We provide a comparative analysis of prediction performance of a battery of data mining techniques using real-life automotive insurance fraud data. While the data we have used in our paper is US-based, the computational techniques we have tested can be adapted and generally applied to detect similar insurance frauds in other countries as well where an organized automotive insurance industry exists

An Empirical Study of AML Approach for Credit Card Fraud Detection—Financial Transactions

Credit card fraud is one of the flip sides of the digital world, where transactions are made without the knowledge of the genuine user. Based on the study of various papers published between 1994 and 2018 on credit card fraud, the following objectives are achieved: the various types of credit card frauds has identified and to detect automatically these frauds, an adaptive machine learning techniques (AMLTs) has studied and also their pros and cons has summarized. The various dataset are used in the literature has studied and categorized into the real and synthesized datasets.The performance matrices and evaluation criteria have summarized which has used to evaluate the fraud detection system.This study has also covered the deep analysis and comparison of the performance (i.e sensitivity, specificity, and accuracy) of existing machine learning techniques in the credit card fraud detection area.The findings of this study clearly show that supervised learning, card-not-present fraud, skimming fraud, and website cloning method has been used more frequently.This Study helps to new researchers by discussing the limitation of existing fraud detection techniques and providing helpful directions of research in the credit card fraud detection field

A Comprehensive Survey of Data Mining-based Fraud Detection Research

This survey paper categorises, compares, and summarises from almost all published technical and review articles in automated fraud detection within the last 10 years. It defines the professional fraudster, formalises the main types and subtypes of known fraud, and presents the nature of data evidence collected within affected industries. Within the business context of mining the data to achieve higher cost savings, this research presents methods and techniques together with their problems. Compared to all related reviews on fraud detection, this survey covers much more technical articles and is the only one, to the best of our knowledge, which proposes alternative data and solutions from related domains.Comment: 14 page

A framework for internal fraud risk reduction at it integrating business processes : the IFR² framework

Fraud is a million dollar business and it is increasing every year. Both internal and external fraud present a substantial cost to our economy worldwide. A review of the academic literature learns that the academic community only addresses external fraud and how to detect this type of fraud. Little or no effort to our knowledge has been put in investigating how to prevent ánd to detect internal fraud, which we call ‘internal fraud risk reduction’. Taking together the urge for research in internal fraud and the lack of it in academic literature, research to reduce internal fraud risk is pivotal. Only after having a framework in which to implement empirical research, this topic can further be investigated. In this paper we present the IFR² framework, deduced from both the academic literature and from current business practices, where the core of this framework suggests to use a data mining approach.El fraude es un negocio millonario y está aumentando cada año. Tanto el fraude interno como el externo presentan un coste considerable para nuestra economía en todo el mundo. Este artículo sobre la literatura académica enseña que la comunidad académica solo se dirige al fraude externo, y cómo se detecta este tipo de fraude. Que sepamos, se ha hecho poco o ningún esfuerzo en investigar cómo evitar y detectar el fraude interno, al que llamamos ‘reducción del riesgo de fraude interno’. Teniendo en cuenta la urgencia de investigar el fraude interno, y la ausencia de ello en la literatura académica, la investigación para reducir este tipo de fraude es esencial. Este tema puede ser aún investigado con mayor profundidad solo después de tener un marco, en el que implementar investigación empírica. En este artículo, presentamos el marco IFR, deducido tanto de la literatura académica como de las prácticas empresariales actuales, donde el foco del marco sugiere usar un enfoque de extracción de datos