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

Feature selection methods for solving the reference class problem

Probabilistic inference from frequencies, such as "Most Quakers are pacifists; Nixon is a Quaker, so probably Nixon is a pacifist" suffer from the problem that an individual is typically a member of many "reference classes" (such as Quakers, Republicans, Californians, etc) in which the frequency of the target attribute varies. How to choose the best class or combine the information? The article argues that the problem can be solved by the feature selection methods used in contemporary Big Data science: the correct reference class is that determined by the features relevant to the target, and relevance is measured by correlation (that is, a feature is relevant if it makes a difference to the frequency of the target)

Combining similarity in time and space for training set formation under concept drift

Concept drift is a challenge in supervised learning for sequential data. It describes a phenomenon when the data distributions change over time. In such a case accuracy of a classifier benefits from the selective sampling for training. We develop a method for training set selection, particularly relevant when the expected drift is gradual. Training set selection at each time step is based on the distance to the target instance. The distance function combines similarity in space and in time. The method determines an optimal training set size online at every time step using cross validation. It is a wrapper approach, it can be used plugging in different base classifiers. The proposed method shows the best accuracy in the peer group on the real and artificial drifting data. The method complexity is reasonable for the field applications