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

An empiric path towards fraud detection and protection for NFC-enabled mobile payment system

The synthesis of NFC technology accompanying mobile payment is a state-of-the-art resolution for payment users. In view of rapid development in electronic payment system there is rise in fraudulent activity in banking transactions associated with credit cards and card-not-present transaction. M-Commerce aid the consumers and helps to bestow real-time information in payment system. Due to the familiarization of m-commerce there is cogent increase in the number of fraudulent activities, emerging in billions of dollar loss every year worldwide. To absolute the security breaches, payment transactions could be confined by considering various parameters like user and device authentication, consumer behavior pattern, geolocation and velocity. In this paper we formally assay NFC-enabled mobile payment fraud detection ecosystem using score-based evaluation method. The fraud detection ecosystem will provide a solution based on transaction risk-modeling, scoring transaction, business rule-based, and cross-field referencing. The score-based evaluation method will analyze the transaction and reckon every transaction for fraud risk and take pertinent decision

An empiric path towards fraud detection and protection for NFC-enabled mobile payment system

The synthesis of NFC technology accompanying mobile payment is a state-of-the-art resolution for payment users. In view of rapid development in electronic payment system there is rise in fraudulent activity in banking transactions associated with credit cards and card-not-present transaction. M-Commerce aid the consumers and helps to bestow real-time information in payment system. Due to the familiarization of m-commerce there is cogent increase in the number of fraudulent activities, emerging in billions of dollar loss every year worldwide. To absolute the security breaches, payment transactions could be confined by considering various parameters like user and device authentication, consumer behavior pattern, geolocation and velocity. In this paper we formally assay NFC-enabled mobile payment fraud detection ecosystem using score-based evaluation method. The fraud detection ecosystem will provide a solution based on transaction risk-modeling, scoring transaction, business rule-based, and cross-field referencing. The score-based evaluation method will analyze the transaction and reckon every transaction for fraud risk and take pertinent decision. Copyright © 2019 Universitas Ahmad Dahlan. All rights reserved

Technology Assessment for Cybersecurity Organizational Readiness: Case of Airlines Sector and Electronic Payment

Payment processing systems have advanced significantly in the airline business. Because e-payments are easy, they have captured the attention of many companies in the aviation industry and are quickly becoming the dominant means of payment. However, as technology advances, fraud grows at a comparable rate. Over the years, there has been a surge in payment fraud incidents in the airline sector, reducing the platform\u27s trustworthiness. Despite attempts to eliminate epayment fraud, decision-makers lack the technical expertise required to use the finest fraud detection and prevention assessments. This research recognizes the lack of an established decision model as a hurdle and seeks to fix the problem. In response, this research aims to develop a decision model for the airline industry to evaluate the e-payment fraud detection and prevention capabilities of airlines. The literature examines the scope of airline payment fraud to formulate the optimal framework to handle the problem. Guided by the results, the study proceeds to develop an HDM model from experts’ validation, quantification, and desirability inputs. The results of the factors’ validation and quantification show that the Economic and Financial, and the Security perspectives have the most impact on decision-making. Airline companies can use the developed framework to examine whether they are ready to adopt online fraud prevention technologies to increase their success rate. To measure payment organizations\u27 readiness for digital payment fraud protection technologies, a scoring methodology was developed in this research and applied to two case studies

Data-Driven Models, Techniques, and Design Principles for Combatting Healthcare Fraud

In the U.S., approximately $700 billion of the$2.7 trillion spent on healthcare is linked to fraud, waste, and abuse. This presents a significant challenge for healthcare payers as they navigate fraudulent activities from dishonest practitioners, sophisticated criminal networks, and even well-intentioned providers who inadvertently submit incorrect billing for legitimate services. This thesis adopts Hevner’s research methodology to guide the creation, assessment, and refinement of a healthcare fraud detection framework and recommended design principles for fraud detection. The thesis provides the following significant contributions to the field:1. A formal literature review of the field of fraud detection in Medicaid. Chapters 3 and 4 provide formal reviews of the available literature on healthcare fraud. Chapter 3 focuses on defining the types of fraud found in healthcare. Chapter 4 reviews fraud detection techniques in literature across healthcare and other industries. Chapter 5 focuses on literature covering fraud detection methodologies utilized explicitly in healthcare.2. A multidimensional data model and analysis techniques for fraud detection in healthcare. Chapter 5 applies Hevner et al. to help develop a framework for fraud detection in Medicaid that provides specific data models and techniques to identify the most prevalent fraud schemes. A multidimensional schema based on Medicaid data and a set of multidimensional models and techniques to detect fraud are presented. These artifacts are evaluated through functional testing against known fraud schemes. This chapter contributes a set of multidimensional data models and analysis techniques that can be used to detect the most prevalent known fraud types.3. A framework for deploying outlier-based fraud detection methods in healthcare. Chapter 6 proposes and evaluates methods for applying outlier detection to healthcare fraud based on literature review, comparative research, direct application on healthcare claims data, and known fraudulent cases. A method for outlier-based fraud detection is presented and evaluated using Medicaid dental claims, providers, and patients.4. Design principles for fraud detection in complex systems. Based on literature and applied research in Medicaid healthcare fraud detection, Chapter 7 offers generalized design principles for fraud detection in similar complex, multi-stakeholder systems.<br/

Mining Bad Credit Card Accounts from OLAP and OLTP

Credit card companies classify accounts as a good or bad based on historical data where a bad account may default on payments in the near future. If an account is classified as a bad account, then further action can be taken to investigate the actual nature of the account and take preventive actions. In addition, marking an account as "good" when it is actually bad, could lead to loss of revenue - and marking an account as "bad" when it is actually good, could lead to loss of business. However, detecting bad credit card accounts in real time from Online Transaction Processing (OLTP) data is challenging due to the volume of data needed to be processed to compute the risk factor. We propose an approach which precomputes and maintains the risk probability of an account based on historical transactions data from offline data or data from a data warehouse. Furthermore, using the most recent OLTP transactional data, risk probability is calculated for the latest transaction and combined with the previously computed risk probability from the data warehouse. If accumulated risk probability crosses a predefined threshold, then the account is treated as a bad account and is flagged for manual verification.Comment: Conference proceedings of ICCDA, 201

An Examination of E-Banking Fraud Prevention and Detection in Nigerian Banks

E-banking offers a number of advantages to financial institutions, including convenience in terms of time and money. However, criminal activities in the information age have changed the way banking operations are performed. This has made e-banking an area of interest. The growth of cybercrime – particularly hacking, identity theft, phishing, Trojans, service denial attacks and account takeover– has created several challenges for financial institutions, especially regarding how they protect their assets and prevent their customers from becoming victims of cyber fraud. These criminal activities have remained prevalent due to certain features of cyber, such as the borderless nature of the internet and the continuous growth of the computer networks. Following these identified challenges for financial institutions, this study examines e-banking fraud prevention and detection in the Nigerian banking sector; particularly the current nature, impacts, contributing factors, and prevention and detection mechanisms of e-banking fraud in Nigerian banking institutions. This study adopts mixed research methods with the aid of descriptive and inferential analysis, which comprised exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) for the quantitative data analysis, whilst thematic analysis was used for the qualitative data analysis. The theoretical framework was informed by Routine Activity Theory (RAT) and Fraud Management Lifecycle Theory (FMLT). The findings show that the factors contributing to the increase in e-banking fraud in Nigeria include ineffective banking operations, internal control issues, lack of customer awareness and bank staff training and education, inadequate infrastructure, presence of sophisticated technological tools in the hands of fraudsters, negligence of banks’ customers concerning their e-banking account devices, lack of compliance with the banking rules and regulations, and ineffective legal procedure and law enforcement. In addition, the enforcement of rules and regulations in relation to the prosecution of financial fraudsters has been passive in Nigeria. Moreover, the findings also show that the activities of each stage of fraud management lifecycle theory are interdependent and have a collective and considerable influence on combating e-banking fraud. The results of the findings confirm that routine activity theory is a real-world theoretical framework while applied to e-banking fraud. Also, from the analysis of the findings, this research offers a new model for e-banking fraud prevention and detection within the Nigerian banking sector. This new model confirms that to have perfect prevention and detection of e-banking fraud, there must be a presence of technological mechanisms, fraud monitoring, effective internal controls, customer complaints, whistle-blowing, surveillance mechanisms, staff-customer awareness and education, legal and judicial controls, institutional synergy mechanisms of in the banking systems. Finally, the findings from the analyses of this study have some significant implications; not only for academic researchers or scholars and accounting practitioners, but also for policymakers in the financial institutions and anti-fraud agencies in both the private and public sectors

Adversarial behaviours knowledge area

The technological advancements witnessed by our society in recent decades have brought improvements in our quality of life, but they have also created a number of opportunities for attackers to cause harm. Before the Internet revolution, most crime and malicious activity generally required a victim and a perpetrator to come into physical contact, and this limited the reach that malicious parties had. Technology has removed the need for physical contact to perform many types of crime, and now attackers can reach victims anywhere in the world, as long as they are connected to the Internet. This has revolutionised the characteristics of crime and warfare, allowing operations that would not have been possible before. In this document, we provide an overview of the malicious operations that are happening on the Internet today. We first provide a taxonomy of malicious activities based on the attacker’s motivations and capabilities, and then move on to the technological and human elements that adversaries require to run a successful operation. We then discuss a number of frameworks that have been proposed to model malicious operations. Since adversarial behaviours are not a purely technical topic, we draw from research in a number of fields (computer science, criminology, war studies). While doing this, we discuss how these frameworks can be used by researchers and practitioners to develop effective mitigations against malicious online operations.Published versio