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

Outlier Mining Methods Based on Graph Structure Analysis

Outlier detection in high-dimensional datasets is a fundamental and challenging problem across disciplines that has also practical implications, as removing outliers from the training set improves the performance of machine learning algorithms. While many outlier mining algorithms have been proposed in the literature, they tend to be valid or efficient for specific types of datasets (time series, images, videos, etc.). Here we propose two methods that can be applied to generic datasets, as long as there is a meaningful measure of distance between pairs of elements of the dataset. Both methods start by defining a graph, where the nodes are the elements of the dataset, and the links have associated weights that are the distances between the nodes. Then, the first method assigns an outlier score based on the percolation (i.e., the fragmentation) of the graph. The second method uses the popular IsoMap non-linear dimensionality reduction algorithm, and assigns an outlier score by comparing the geodesic distances with the distances in the reduced space. We test these algorithms on real and synthetic datasets and show that they either outperform, or perform on par with other popular outlier detection methods. A main advantage of the percolation method is that is parameter free and therefore, it does not require any training; on the other hand, the IsoMap method has two integer number parameters, and when they are appropriately selected, the method performs similar to or better than all the other methods tested.Peer ReviewedPostprint (published version

Artificial Intelligence Adoption in Criminal Incestigations: Challenges and Opportunities for Research

Artificial Intelligence (AI) offers the potential to transform organisational decision-making and knowledge-sharing processes that support criminal investigations. Yet, there is still limited evidence-based knowledge concerning the successful use of AI for criminal investigations in literature. This paper identifies the main areas and current dynamics of the adoption of AI in criminal investigations using bibliometric analysis. We synthesise existing research by identifying key themes researchers have delved into on AI in criminal investigations. The themes include crime prediction and human-centred issues relating to AI use in criminal investigations. Finally, the paper elaborates on the challenges that may influence AI adoption in criminal investigations by police professionals. These challenges include possible laggard effects with AI adoption, implementation challenges, lack of government oversight, and a skills gap

Data mining for detecting Bitcoin Ponzi schemes

Soon after its introduction in 2009, Bitcoin has been adopted by cyber-criminals, which rely on its pseudonymity to implement virtually untraceable scams. One of the typical scams that operate on Bitcoin are the so-called Ponzi schemes. These are fraudulent investments which repay users with the funds invested by new users that join the scheme, and implode when it is no longer possible to find new investments. Despite being illegal in many countries, Ponzi schemes are now proliferating on Bitcoin, and they keep alluring new victims, who are plundered of millions of dollars. We apply data mining techniques to detect Bitcoin addresses related to Ponzi schemes. Our starting point is a dataset of features of real-world Ponzi schemes, that we construct by analysing, on the Bitcoin blockchain, the transactions used to perform the scams. We use this dataset to experiment with various machine learning algorithms, and we assess their effectiveness through standard validation protocols and performance metrics. The best of the classifiers we have experimented can identify most of the Ponzi schemes in the dataset, with a low number of false positives

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

Application of Machine Learning Techniques in Credit Card Fraud Detection

Credit card fraud is an ever-growing problem in today’s financial market. There has been a rapid increase in the rate of fraudulent activities in recent years causing a substantial financial loss to many organizations, companies, and government agencies. The numbers are expected to increase in the future, because of which, many researchers in this field have focused on detecting fraudulent behaviors early using advanced machine learning techniques. However, the credit card fraud detection is not a straightforward task mainly because of two reasons: (i) the fraudulent behaviors usually differ for each attempt and (ii) the dataset is highly imbalanced, i.e., the frequency of majority samples (genuine cases) outnumbers the minority samples (fraudulent cases). When providing input data of a highly unbalanced class distribution to the predictive model, the model tends to be biased towards the majority samples. As a result, it tends to misrepresent a fraudulent transaction as a genuine transaction. To tackle this problem, data-level approach, where different resampling methods such as undersampling, oversampling, and hybrid strategies, have been implemented along with an algorithmic approach where ensemble models such as bagging and boosting have been applied to a highly skewed dataset containing 284807 transactions. Out of these transactions, only 492 transactions are labeled as fraudulent. Predictive models such as logistic regression, random forest, and XGBoost in combination with different resampling techniques have been applied to predict if a transaction is fraudulent or genuine. The performance of the model is evaluated based on recall, precision, f1-score, precision-recall (PR) curve, and receiver operating characteristics (ROC) curve. The experimental results showed that random forest in combination with a hybrid resampling approach of Synthetic Minority Over-sampling Technique (SMOTE) and Tomek Links removal performed better than other models