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

Credit card fraud detection by adaptive neural data mining

The prevention of credit card fraud is an important application for prediction techniques. One major obstacle for using neural network training techniques is the high necessary diagnostic quality: Since only one financial transaction of a thousand is invalid no prediction success less than 99.9% is acceptable. Due to these credit card transaction proportions complete new concepts had to be developed and tested on real credit card data. This paper shows how advanced data mining techniques and neural network algorithm can be combined successfully to obtain a high fraud coverage combined with a low false alarm rate

An Overview of the Use of Neural Networks for Data Mining Tasks

In the recent years the area of data mining has experienced a considerable demand for technologies that extract knowledge from large and complex data sources. There is a substantial commercial interest as well as research investigations in the area that aim to develop new and improved approaches for extracting information, relationships, and patterns from datasets. Artificial Neural Networks (NN) are popular biologically inspired intelligent methodologies, whose classification, prediction and pattern recognition capabilities have been utilised successfully in many areas, including science, engineering, medicine, business, banking, telecommunication, and many other fields. This paper highlights from a data mining perspective the implementation of NN, using supervised and unsupervised learning, for pattern recognition, classification, prediction and cluster analysis, and focuses the discussion on their usage in bioinformatics and financial data analysis tasks

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

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

Implementing Peer Group Analysis within a Track and Trace System to Detect Potential Fraud(s)

Tracking and tracing of goods movement is a key requirement for supply chain management and analysis. Data collection can be broad and large in volumes. Goods can moves in complex supply chain distributions, where disputes, frauds and thefts can happens. This paper aimed to develop a practical method to analyze the incoming data and employ unsupervised potential fraud detection in near real-time. The method is designed and discussed around peer group analysis (PGA) approach which is commonly used in financial market. The paper shall focus on two steps. First, monitor and groups good movements and categorize vendors or suppliers with similar trend / behaviours into dedicatedpeers. Second build a tool / services that detect anomalies in event transactions. The monitoring serviceshalldetect the outlier orindividual objects that distinct from peers whichpotentially fraud /alerts

A ‘criminal personas’ approach to countering criminal creativity

This paper describes a pilot study of a ‘criminal personas’ approach to countering criminal creativity. The value of the personas approach has been assessed by comparing the identification of criminal opportunity, through ‘traditional’ brainstorming and then through ‘criminal personas’ brainstorming The method involved brainstorm sessions with Computer Forensics Practitioners and with Product Designers, where they were required to generate criminal scenarios, select the most serious criminal opportunities, and propose means of countering them. The findings indicated that there was merit in further research in the development and application of the ‘criminal personas’ approach. The generation of criminal opportunity ideas and proposal of counter criminal solutions were both greater when the brainstorm approach involved the group responding through their given criminal personas