Uncovering Insurance Fraud Conspiracy with Network Learning

Fraudulent claim detection is one of the greatest challenges the insurance industry faces. Alibaba's return-freight insurance, providing return-shipping postage compensations over product return on the e-commerce platform, receives thousands of potentially fraudulent claims every day. Such deliberate abuse of the insurance policy could lead to heavy financial losses. In order to detect and prevent fraudulent insurance claims, we developed a novel data-driven procedure to identify groups of organized fraudsters, one of the major contributions to financial losses, by learning network information. In this paper, we introduce a device-sharing network among claimants, followed by developing an automated solution for fraud detection based on graph learning algorithms, to separate fraudsters from regular customers and uncover groups of organized fraudsters. This solution applied at Alibaba achieves more than 80% precision while covering 44% more suspicious accounts compared with a previously deployed rule-based classifier after human expert investigations. Our approach can easily and effectively generalizes to other types of insurance.Comment: Accepted by SIGIR '19. Proceedings of the 42nd International ACM SIGIR Conference on Research and Development in Information Retrieval. 201

Modeling the Field Value Variations and Field Interactions Simultaneously for Fraud Detection

With the explosive growth of e-commerce, online transaction fraud has become one of the biggest challenges for e-commerce platforms. The historical behaviors of users provide rich information for digging into the users' fraud risk. While considerable efforts have been made in this direction, a long-standing challenge is how to effectively exploit internal user information and provide explainable prediction results. In fact, the value variations of same field from different events and the interactions of different fields inside one event have proven to be strong indicators for fraudulent behaviors. In this paper, we propose the Dual Importance-aware Factorization Machines (DIFM), which exploits the internal field information among users' behavior sequence from dual perspectives, i.e., field value variations and field interactions simultaneously for fraud detection. The proposed model is deployed in the risk management system of one of the world's largest e-commerce platforms, which utilize it to provide real-time transaction fraud detection. Experimental results on real industrial data from different regions in the platform clearly demonstrate that our model achieves significant improvements compared with various state-of-the-art baseline models. Moreover, the DIFM could also give an insight into the explanation of the prediction results from dual perspectives.Comment: 11 pages, 4 figure

xFraud: Explainable Fraud Transaction Detection

At online retail platforms, it is crucial to actively detect the risks of transactions to improve customer experience and minimize financial loss. In this work, we propose xFraud, an explainable fraud transaction prediction framework which is mainly composed of a detector and an explainer. The xFraud detector can effectively and efficiently predict the legitimacy of incoming transactions. Specifically, it utilizes a heterogeneous graph neural network to learn expressive representations from the informative heterogeneously typed entities in the transaction logs. The explainer in xFraud can generate meaningful and human-understandable explanations from graphs to facilitate further processes in the business unit. In our experiments with xFraud on real transaction networks with up to 1.1 billion nodes and 3.7 billion edges, xFraud is able to outperform various baseline models in many evaluation metrics while remaining scalable in distributed settings. In addition, we show that xFraud explainer can generate reasonable explanations to significantly assist the business analysis via both quantitative and qualitative evaluations.Comment: This is the extended version of a full paper to appear in PVLDB 15 (3) (VLDB 2022

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/