2 research outputs found
Prescription Fraud detection via data mining : a methodology proposal
Ankara : The Department of Industrial Engineering and the Institute of Engineering and Science of Bilkent University, 2009.Thesis (Master's) -- -Bilkent University, 2009.Includes bibliographical references leaves 61-69Fraud is the illegitimate act of violating regulations in order to gain personal profit.
These kinds of violations are seen in many important areas including, healthcare, computer
networks, credit card transactions and communications. Every year health care fraud causes
considerable amount of losses to Social Security Agencies and Insurance Companies in many
countries including Turkey and USA. This kind of crime is often seem victimless by the
committers, nonetheless the fraudulent chain between pharmaceutical companies, health care
providers, patients and pharmacies not only damage the health care system with the financial
burden but also greatly hinders the health care system to provide legitimate patients with
quality health care. One of the biggest issues related with health care fraud is the prescription
fraud. This thesis aims to identify a data mining methodology in order to detect fraudulent
prescriptions in a large prescription database, which is a task traditionally conducted by
human experts. For this purpose, we have developed a customized data-mining model for the
prescription fraud detection. We employ data mining methodologies for assigning a risk score
to prescriptions regarding Prescribed Medicament- Diagnosis consistency, Prescribed
Medicaments’ consistency within a prescription, Prescribed Medicament- Age and Sex
consistency and Diagnosis- Cost consistency. Our proposed model has been tested on real
world data. The results we obtained from our experimentations reveal that the proposed model
works considerably well for the prescription fraud detection problem with a 77.4% true
positive rate. We conclude that incorporating such a system in Social Security Agencies
would radically decrease human-expert auditing costs and efficiency.Aral, Karca DuruM.S