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

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

Dissociating What and When of Intentional Actions

Recent brain imaging research revealed that internally guided actions involve the frontomedian wall, in particular the preSMA and the rostral cingulate zone (RCZ). However, a systematic decomposition of different components of intentional action is still lacking. We propose a new paradigm to dissociate two components of internally guided behavior: Which action to perform (selection component) and when to perform the action (timing component). Our results suggest a neuro-functional dissociation of intentional action timing and intentional action selection. While the RCZ is more strongly activated for the selection component, a part of the superior medial frontal gyrus is more strongly activated for the timing component. However, in a post hoc conducted signal strength analysis we did also observe an interaction between action timing and action selection, indicating that decisional processes concerning action timing and action selection are not completely dissociated but interdependent. Altogether this study challenges the idea of a unitary system supporting voluntary action and instead suggests the existence of different neuroanatomically dissociable subfunctions

Qualitative Nachverdichtungsberatung als Mittel zur Steigerung des Wohnraumangebots in Zeiten von steigenden Baulandpreisen

Viele Problemfelder beschäftigen derzeit Städte bei der Wohnraumschaffung. Zum einen stehen sie vor der Herausforderung, dem steigenden Siedlungsdruck trotz der begrenzten Flächenverfügbarkeit entgegenzuwirken und den Wohnungsbedarf zu decken. Darüber hinaus gibt es in vielen Städten einen hohen Anteil an Ein- und Zweifamilienhäusern und eine damit verbundene ineffiziente Flächennutzung. Aufgrund dieser Ausgangssituation und durch den akuten und stetigen Anstieg der Preise für Bauland und Baumaterialien sind innovative Lösungen hinsichtlich der zusätzlichen Schaffung von Wohnraum gefragt. Eine Möglichkeit bietet die Mobilisierung und Ausschöpfung vorhandener Nachverdichtungspotenziale in den Städten. Das Projekt BONUS setzt genau hier an und integriert zusätzlich, neben energieeffizienten Sanierungsmaßnahmen, mit den Themenfeldern Grün- und Freiraum sowie Mobilität weitere Aspekte in die Nachverdichtung. Somit sollen negative Begleiterscheinungen von Nachverdichtungsprozessen wie die Reduzierung von qualitativen Grünraum oder die Steigerung des privaten PKW-Verkehrs verringert werden. Durch den modularen Aufbau der BONUS-Nachverdichtungsberatung in zwei Beratungsstufen kann individuell auf die Vorstellungen und Wünsche der Eigentümer*innen eingegangen werden. Den Eigentümer*innen bietet sich so die Möglichkeit im Vergleich zum Neubau, beispielsweise Familienmitgliedern eine kostengünstigere Alternative zum Einfamilienhaus zu bieten. Unterstützt werden die Nachverdichtungsberater*innen von unterschiedlichen Beratungswerkzeugen wie einem Fragebogen oder einem Datenblatt mit Informationen zum Grundstück, wie dem potenziellen Nachverdichtungspotenzial. Grundlage dafür bilden eine innovative Datenbasis und innovative GIS-Methoden, die auf andere Gemeinden übertragbar sind und den Berater*innen eine optimale Vorbereitung für die Beratungstermine bieten

MiR-200c-3p modulates cisplatin resistance in biliary tract cancer by ZEB1-independent mechanisms

Biliary tract cancer is a major global health issue in cancer-related mortality. Therapeutic options are limited, and cisplatin-based treatment schedules represent the mainstay of first-line therapeutic strategies. Although the gain of survival by the addition of cisplatin to gemcitabine is moderate, acquired cisplatin resistance frequently leads to treatment failures with mechanisms that are still poorly understood. Epithelial–mesenchymal transition (EMT) is a dynamic process that changes the shape, function, and gene expression pattern of biliary tract cancer cells. In this study, we explored the influence of the EMT-regulating miR-200c-3p on cisplatin sensitivity in biliary tract cancer cells. Using gain of function experiments, we demonstrated that miR-200c-3p regulates epithelial cell markers through the downregulation of the transcription factor ZEB1. MiR-200c-3p upregulation led to a decreased sensitivity against cisplatin, as observed in transient overexpression models as well as in cell lines stably overexpressing miR-200c-3p. The underlying mechanism seems to be independent of miR-200c-3p’s influence on ZEB1 expression, as ZEB1 knockdown resulted in the opposite effect on cisplatin resistance, which was abolished when ZEB1 knockdown and miR-200c-3p overexpression occurred in parallel. Using a gene panel of 40 genes that were previously associated with cisplatin resistance, two (Dual Specificity Phosphatase 16 (DUSP16) and Stratifin (SFN)) were identified as significantly (>2 fold, p-value < 0.05) up-regulated in miR-200c-3p overexpressing cells. In conclusion, miR-200c-3p might be an important contributor to cisplatin resistance in biliary tract cancer, independently of its interaction with ZEB1

TGF-β inhibitor Smad7 regulates dendritic cell-induced autoimmunity

TGF-β is an anti-inflammatory cytokine whose signaling is negatively controlled by Smad7. Previously, we established a role for Smad7 in the generation of autoreactive T cells; however, the function of Smad7 in dendritic cells (DCs) remains elusive. Here, we demonstrate that DC-specific Smad7 deficiency resulted in elevated expression of the transcription factors Batf3 and IRF8, leading to increased frequencies of CD8(+)CD103(+) DCs in the spleen. Furthermore, Smad7-deficient DCs expressed higher levels of indoleamine 2,3-dioxygenase (IDO), an enzyme associated with tolerance induction. Mice devoid of Smad7 specifically in DCs are resistant to the development of experimental autoimmune encephalomyelitis (EAE) as a result of an increase of protective regulatory T cells (Tregs) and reduction of encephalitogenic effector T cells in the central nervous system. In agreement, inhibition of IDO activity or depletion of Tregs restored disease susceptibility. Intriguingly, when Smad7-deficient DCs also lacked the IFN-γ receptor, the mice regained susceptibility to EAE, demonstrating that IFN-γ signaling in DCs mediates their tolerogenic function. Our data indicate that Smad7 expression governs splenic DC subset differentiation and is critical for the promotion of their efficient function in immunity

OpenLB User Guide: Associated with Release 1.6 of the Code

OpenLB is an object-oriented implementation of LBM. It is the first implementation of a generic platform for LBM programming, which is shared with the open source community (GPLv2). Since the first release in 2007, the code has been continuously improved and extended which is documented by thirteen releases as well as the corresponding release notes which are available on the OpenLB website (https://www.openlb.net). The OpenLB code is written in C++ and is used by application programmers as well as developers, with the ability to implement custom models OpenLB supports complex data structures that allow simulations in complex geometries and parallel execution using MPI, OpenMP and CUDA on high-performance computers. The source code uses the concepts of interfaces and templates, so that efficient, direct and intuitive implementations of the LBM become possible. The efficiency and scalability has been checked and proved by code reviews. This user manual and a source code documentation by DoxyGen are available on the OpenLB project website

PrImary decompressive Craniectomy in AneurySmal Subarachnoid hemOrrhage (PICASSO) trial: study protocol for a randomized controlled trial

BACKGROUND: Poor-grade aneurysmal subarachnoid hemorrhage (SAH) is associated with poor neurological outcome and high mortality. A major factor influencing morbidity and mortality is brain swelling in the acute phase. Decompressive craniectomy (DC) is currently used as an option in order to reduce intractably elevated intracranial pressure (ICP). However, execution and optimal timing of DC remain unclear. METHODS: PICASSO resembles a multicentric, prospective, 1:1 randomized standard treatment-controlled trial which analyzes whether primary DC (pDC) performed within 24 h combined with the best medical treatment in patients with poor-grade SAH reduces mortality and severe disability in comparison to best medical treatment alone and secondary craniectomy as ultima ratio therapy for elevated ICP. Consecutive patients presenting with poor-grade SAH, defined as grade 4–5 according to the World Federation of Neurosurgical Societies (WFNS), will be screened for eligibility. Two hundred sixteen patients will be randomized to receive either pDC additional to best medical treatment or best medical treatment alone. The primary outcome is the clinical outcome according to the modified Rankin Scale (mRS) at 12 months, which is dichotomized to favorable (mRS 0–4) and unfavorable (mRS 5–6). Secondary outcomes include morbidity and mortality, time to death, length of intensive care unit (ICU) stay and hospital stay, quality of life, rate of secondary DC due to intractably elevated ICP, effect of size of DC on outcome, use of duraplasty, and complications of DC. DISCUSSION: This multicenter trial aims to generate the first confirmatory data in a controlled randomized fashion that pDC improves the outcome in a clinically relevant endpoint in poor-grade SAH patients. TRIAL REGISTRATION: DRKS DRKS00017650. Registered on 09 June 2019. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s13063-022-06969-4