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/

An Intelligent Data Mining System to Detect Health Care Fraud

The chapter begins with an overview of the types of healthcare fraud. Next, there is a brief discussion of issues with the current fraud detection approaches. The chapter then develops information technology based approaches and illustrates how these technologies can improve current practice. Finally, there is a summary of the major findings and the implications for healthcare practice

Meta-analysis of fraud, waste and abuse detection methods in healthcare

Fraud, waste and abuse have been a concern in healthcare system due to the exponential increase in the loss of revenue, loss of reputation and goodwill, and a rapid decline in the relationship between healthcare providers and patients. Consequently, fraud, waste and abuse result in a high cost of healthcare services, decreased quality of care, and threat to patients’ lives. Its enormous side effects in healthcare have attracted diverse efforts in the healthcare industry, data analytics industry and research communities towards the development of fraud detection methods. Hence, this study examines and analyzes fraud, waste and abuse detection methods used in healthcare, to reveal the strengths and limitations of each approach. Eighty eight literatures obtained from journal articles, conference proceedings and books based on their relevance to the research problem were reviewed. The result of this review revealed that fraud detection methods are difficult to implement in the healthcare system because new fraud patterns are constantly developed to circumvent fraud detection methods. Research in medical fraud assessment is limited due to data limitations as well as privacy and confidentiality concerns.Keywords: abuse, fraud, healthcare, waste, fraud detection method

Unsupervised learning for anomaly detection in Australian medical payment data

Fraudulent or wasteful medical insurance claims made by health care providers are costly for insurers. Typically, OECD healthcare organisations lose 3-8% of total expenditure due to fraud. As Australia’s universal public health insurer, Medicare Australia, spends approximately $A 34 billion per annum on the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme, wasted spending of$A1–2.7 billion could be expected.However, fewer than 1% of claims to Medicare Australia are detected as fraudulent, below international benchmarks. Variation is common in medicine, and health conditions, along with their presentation and treatment, are heterogenous by nature. Increasing volumes of data and rapidly changing patterns bring challenges which require novel solutions. Machine learning and data mining are becoming commonplace in this field, but no gold standard is yet available. In this project, requirements are developed for real-world application to compliance analytics at the Australian Government Department of Health and Aged Care (DoH), covering: unsupervised learning; problem generalisation; human interpretability; context discovery; and cost prediction. Three novel methods are presented which rank providers by potentially recoverable costs. These methods used association analysis, topic modelling, and sequential pattern mining to provide interpretable, expert-editable models of typical provider claims. Anomalous providers are identified through comparison to the typical models, using metrics based on costs of excess or upgraded services. Domain knowledge is incorporated in a machine-friendly way in two of the methods through the use of the MBS as an ontology. Validation by subject-matter experts and comparison to existing techniques shows that the methods perform well. The methods are implemented in a software framework which enables rapid prototyping and quality assurance. The code is implemented at the DoH, and further applications as decision-support systems are in progress. The developed requirements will apply to future work in this fiel

진료 내역 데이터를 활용한 딥러닝 기반의 건강보험 남용 탐지

학위논문 (박사) -- 서울대학교 대학원 : 공과대학 산업공학과, 2020. 8. 조성준.As global life expectancy increases, spending on healthcare grows in accordance in order to improve quality of life. However, due to expensive price of medical care, the bare cost of healthcare services would inevitably places great financial burden to individuals and households. In this light, many countries have devised and established their own public healthcare insurance systems to help people receive medical services at a lower price. Since reimbursements are made ex-post, unethical practices arise, exploiting the post-payment structure of the insurance system. The archetypes of such behavior are overdiagnosis, the act of manipulating patients diseases, and overtreatments, prescribing unnecessary drugs for the patient. These abusive behaviors are considered as one of the main sources of financial loss incurred in the healthcare system. In order to detect and prevent abuse, the national healthcare insurance hires medical professionals to manually examine whether the claim filing is medically legitimate or not. However, the review process is, unquestionably, very costly and time-consuming. In order to address these limitations, data mining techniques have been employed to detect problematic claims or abusive providers showing an abnormal billing pattern. However, these cases only used coarsely grained information such as claim-level or provider-level data. This extracted information may lead to degradation of the model's performance. In this thesis, we proposed abuse detection methods using the medical treatment data, which is the lowest level information of the healthcare insurance claim. Firstly, we propose a scoring model based on which abusive providers are detected and show that the review process with the proposed model is more efficient than that with the previous model which uses the provider-level variables as input variables. At the same time, we devise the evaluation metrics to quantify the efficiency of the review process. Secondly, we propose the method of detecting overtreatment under seasonality, which reflects more reality to the model. We propose a model embodying multiple structures specific to DRG codes selected as important for each given department. We show that the proposed method is more robust to the seasonality than the previous method. Thirdly, we propose an overtreatment detection model accounting for heterogeneous treatment between practitioners. We proposed a network-based approach through which the relationship between the diseases and treatments is considered during the overtreatment detection process. Experimental results show that the proposed method classify the treatment well which does not explicitly exist in the training set. From these works, we show that using treatment data allows modeling abuse detection at various levels: treatment, claim, and provider-level.사람들의 기대수명이 증가함에 따라 삶의 질을 향상시키기 위해 보건의료에 소비하는 금액은 증가하고 있다. 그러나, 비싼 의료 서비스 비용은 필연적으로 개인과 가정에게 큰 재정적 부담을 주게된다. 이를 방지하기 위해, 많은 국가에서는 공공 의료 보험 시스템을 도입하여 사람들이 적절한 가격에 의료서비스를 받을 수 있도록 하고 있다. 일반적으로, 환자가 먼저 서비스를 받고 나서 일부만 지불하고 나면, 보험 회사가 사후에 해당 의료 기관에 잔여 금액을 상환을 하는 제도로 운영된다. 그러나 이러한 제도를 악용하여 환자의 질병을 조작하거나 과잉진료를 하는 등의 부당청구가 발생하기도 한다. 이러한 행위들은 의료 시스템에서 발생하는 주요 재정 손실의 이유 중 하나로, 이를 방지하기 위해, 보험회사에서는 의료 전문가를 고용하여 의학적 정당성여부를 일일히 검사한다. 그러나, 이러한 검토과정은 매우 비싸고 많은 시간이 소요된다. 이러한 검토과정을 효율적으로 하기 위해, 데이터마이닝 기법을 활용하여 문제가 있는 청구서나 청구 패턴이 비정상적인 의료 서비스 공급자를 탐지하는 연구가 있어왔다. 그러나, 이러한 연구들은 데이터로부터 청구서 단위나 공급자 단위의 변수를 유도하여 모델을 학습한 사례들로, 가장 낮은 단위의 데이터인 진료 내역 데이터를 활용하지 못했다. 이 논문에서는 청구서에서 가장 낮은 단위의 데이터인 진료 내역 데이터를 활용하여 부당청구를 탐지하는 방법론을 제안한다. 첫째, 비정상적인 청구 패턴을 갖는 의료 서비스 제공자를 탐지하는 방법론을 제안하였다. 이를 실제 데이터에 적용하였을 때, 기존의 공급자 단위의 변수를 사용한 방법보다 더 효율적인 심사가 이루어 짐을 확인하였다. 이 때, 효율성을 정량화하기 위한 평가 척도도 제안하였다. 둘째로, 청구서의 계절성이 존재하는 상황에서 과잉진료를 탐지하는 방법을 제안하였다. 이 때, 진료 과목단위로 모델을 운영하는 대신 질병군(DRG) 단위로 모델을 학습하고 평가하는 방법을 제안하였다. 그리고 실제 데이터에 적용하였을 때, 제안한 방법이 기존 방법보다 계절성에 더 강건함을 확인하였다. 셋째로, 동일 환자에 대해서 의사간의 상이한 진료 패턴을 갖는 환경에서의 과잉진료 탐지 방법을 제안하였다. 이는 환자의 질병과 진료내역간의 관계를 네트워크 기반으로 모델링하는것을 기반으로 한다. 실험 결과 제안한 방법이 학습 데이터에서 나타나지 않는 진료 패턴에 대해서도 잘 분류함을 알 수 있었다. 그리고 이러한 연구들로부터 진료 내역을 활용하였을 때, 진료내역, 청구서, 의료 서비스 제공자 등 다양한 레벨에서의 부당 청구를 탐지할 수 있음을 확인하였다.Chapter 1 Introduction 1 Chapter 2 Detection of Abusive Providers by department with Neural Network 9 2.1 Background 9 2.2 Literature Review 12 2.2.1 Abnormality Detection in Healthcare Insurance with Datamining Technique 12 2.2.2 Feed-Forward Neural Network 17 2.3 Proposed Method 21 2.3.1 Calculating the Likelihood of Abuse for each Treatment with Deep Neural Network 22 2.3.2 Calculating the Abuse Score of the Provider 25 2.4 Experiments 26 2.4.1 Data Description 27 2.4.2 Experimental Settings 32 2.4.3 Evaluation Measure (1): Relative Efficiency 33 2.4.4 Evaluation Measure (2): Precision at k 37 2.5 Results 38 2.5.1 Results in the test set 38 2.5.2 The Relationship among the Claimed Amount, the Abused Amount and the Abuse Score 40 2.5.3 The Relationship between the Performance of the Treatment Scoring Model and Review Efficiency 41 2.5.4 Treatment Scoring Model Results 42 2.5.5 Post-deployment Performance 44 2.6 Summary 45 Chapter 3 Detection of overtreatment by Diagnosis-related Group with Neural Network 48 3.1 Background 48 3.2 Literature review 51 3.2.1 Seasonality in disease 51 3.2.2 Diagnosis related group 52 3.3 Proposed method 54 3.3.1 Training a deep neural network model for treatment classi fication 55 3.3.2 Comparing the Performance of DRG-based Model against the department-based Model 57 3.4 Experiments 60 3.4.1 Data Description and Preprocessing 60 3.4.2 Performance Measures 64 3.4.3 Experimental Settings 65 3.5 Results 65 3.5.1 Overtreatment Detection 65 3.5.2 Abnormal Claim Detection 67 3.6 Summary 68 Chapter 4 Detection of overtreatment with graph embedding of disease-treatment pair 70 4.1 Background 70 4.2 Literature review 72 4.2.1 Graph embedding methods 73 4.2.2 Application of graph embedding methods to biomedical data analysis 79 4.2.3 Medical concept embedding methods 87 4.3 Proposed method 88 4.3.1 Network construction 89 4.3.2 Link Prediction between the Disease and the Treatment 90 4.3.3 Overtreatment Detection 93 4.4 Experiments 96 4.4.1 Data Description 97 4.4.2 Experimental Settings 99 4.5 Results 102 4.5.1 Network Construction 102 4.5.2 Link Prediction between the Disease and the Treatment 104 4.5.3 Overtreatment Detection 105 4.6 Summary 106 Chapter 5 Conclusion 108 5.1 Contribution 108 5.2 Future Work 110 Bibliography 112 국문초록 129Docto

Exploration of Data Science Toolbox and Predictive Models to Detect and Prevent Medicare Fraud, Waste, and Abuse

The Federal Department of Health and Human Services spends approximately $830 Billion annually on Medicare of which an estimated$30 to $110 billion is some form of fraud, waste, or abuse (FWA). Despite the Federal Government’s ongoing auditing efforts, fraud, waste, and abuse is rampant and requires modern machine learning approaches to generalize and detect such patterns. New and novel machine learning algorithms offer hope to help detect fraud, waste, and abuse. The existence of publicly accessible datasets complied by The Centers for Medicare & Medicaid Services (CMS) contain vast quantities of structured data. This data, coupled with industry standardized billing codes provides many opportunities for the application of machine learning for fraud, waste, and abuse detection. This research aims to develop a new model utilizing machine learning to generalize the patterns of fraud, waste, and abuse in Medicare. This task is accomplished by linking provider and payment data with the list of excluded individuals and entities to train an Isolation Forest algorithm on previously fraudulent behavior. Results indicate anomalous instances occurring in 0.2% of all analyzed claims, demonstrating machine learning models’ predictive ability to detect FWA

Fraud: and anomaly detection in healthcare: an unsupervised machine learning approach

Internship Report presented as the partial requirement for obtaining a Master's degree in Data Science and Advanced Analytics, specialization in Business AnalyticsFraud and abuse in healthcare are critical and cause significant damage. However, the auditing of healthcare encounters is cumbersome, and the detection of fraud and abuse is challenging and binds capacity. Data-driven fraud and anomaly detection models can help to overcome these issues. This work proposes several unsupervised learning methods to understand patterns and detect abnormal healthcare encounters which might be fraudulent or abusive. The ensemble of models is split into sub-processes and applied on a healthcare data set belonging to Future Healthcare group, a Portuguese group acting in health insurance. One major part of the ensemble is the implementation of the Isolation Forest algorithm, which achieves good results in precision and recall and detect new potential fraudulent abnormal behaviour. Due to unlabelled data and the application of unsupervised learning methods, the proposed model detects new fraudulent patterns instead of learning from existing patterns. Besides the model to predict whether new incoming medical encounters are fraudulent or abusive, this work illustrates a visual method to detect suspicious networks among medical providers. In addition, this work contains an approach to predict whether a customer will cancel the insurance based on anomalous behaviour. This internship report aims to contribute to science and be public, even though some parts could not be explained in detail due to confidentiality

Show Me Your Claims and I\u27ll Tell You Your Offenses: Machine Learning-Based Decision Support for Fraud Detection on Medical Claim Data

Health insurance claim fraud is a serious issue for the healthcare industry as it drives up costs and inefficiency. Therefore, claim fraud must be effectively detected to provide economical and high-quality healthcare. In practice, however, fraud detection is mainly performed by domain experts resulting in significant cost and resource consumption. This paper presents a novel Convolutional Neural Network-based fraud detection approach that was developed, implemented, and evaluated on Medicare Part B records. The model aids manual fraud detection by classifying potential types of fraud, which can then be specifically analyzed. Our model is the first of its kind for Medicare data, yields an AUC of 0.7 for selected fraud types and provides an applicable method for medical claim fraud detection

Show Me Your Claims and I'll Tell You Your Offenses: Machine Learning-Based Decision Support for Fraud Detection on Medical Claim Data

Health insurance claim fraud is a serious issue for the healthcare industry as it drives up costs and inefficiency. Therefore, claim fraud must be effectively detected to provide economical and high-quality healthcare. In practice, however, fraud detection is mainly performed by domain experts resulting in significant cost and resource consumption. This paper presents a novel Convolutional Neural Network-based fraud detection approach that was developed, implemented, and evaluated on Medicare Part B records. The model aids manual fraud detection by classifying potential types of fraud, which can then be specifically analyzed. Our model is the first of its kind for Medicare data, yields an AUC of 0.7 for selected fraud types and provides an applicable method for medical claim fraud detection