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

Forgery in Cyberspace: The Spoof Could Be on You!

Spoofing is one of the newest forms of cyber-attack, a technological methodology adapted to mask the identity of spammers who have faced hostile reaction in response to bulk, unsolicited, electronic mail messages.[1] Sending Spam, however, is no longer the only reason for deception, as crackers have taken pleasure in the challenge of manipulating computer systems and, additionally, find recreational enjoyment in doing so. In this legal Note, the author’s intent is to show that criminal, rather than civil liability is the best way to effectively deter and punish the spoofer. The injury that results when a computer system’s technological safety measures fail to adequately safeguard the system affects not only the owner of the hijacked e-mail address, but also the Internet Service Provider, and the Network as a whole. Current Anti-Spam Legislation is arguably ineffective at targeting these particular types of malicious attacks, and a different legal approach is suggested

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

Electronic security - risk mitigation in financial transactions : public policy issues

This paper builds on a previous series of papers (see Claessens, Glaessner, and Klingebiel, 2001, 2002) that identified electronic security as a key component to the delivery of electronic finance benefits. This paper and its technical annexes (available separately at http://www1.worldbank.org/finance/) identify and discuss seven key pillars necessary to fostering a secure electronic environment. Hence, it is intended for those formulating broad policies in the area of electronic security and those working with financial services providers (for example, executives and management). The detailed annexes of this paper are especially relevant for chief information and security officers responsible for establishing layered security. First, this paper provides definitions of electronic finance and electronic security and explains why these issues deserve attention. Next, it presents a picture of the burgeoning global electronic security industry. Then it develops a risk-management framework for understanding the risks and tradeoffs inherent in the electronic security infrastructure. It also provides examples of tradeoffs that may arise with respect to technological innovation, privacy, quality of service, and security in designing an electronic security policy framework. Finally, it outlines issues in seven interrelated areas that often need attention in building an adequate electronic security infrastructure. These are: 1) The legal framework and enforcement. 2) Electronic security of payment systems. 3) Supervision and prevention challenges. 4) The role of private insurance as an essential monitoring mechanism. 5) Certification, standards, and the role of the public and private sectors. 6) Improving the accuracy of information on electronic security incidents and creating better arrangements for sharing this information. 7) Improving overall education on these issues as a key to enhancing prevention.Knowledge Economy,Labor Policies,International Terrorism&Counterterrorism,Payment Systems&Infrastructure,Banks&Banking Reform,Education for the Knowledge Economy,Knowledge Economy,Banks&Banking Reform,International Terrorism&Counterterrorism,Governance Indicators