Using Benford\u27s Law to Detect Fraud in the Insurance Industry

Benford\u27s Law is the mathematical phenomena that states that the first digits or left most digits in a list of numbers will occur with an expected logarithmic frequency. While this method has been used in industries such as oil and gas and manufacturing to identify fraudulent activity, it has not been applied to the health insurance industry. Since health insurance companies process a large number of claims each year and these claims are susceptible to fraud, the use of this method in this industry is appropriate. This paper examines the application of Benford\u27s Law to four health insurance companies located in the Midwest. For each company, analysis was performed on the first digit distribution, the first two-digit distribution, and providers with high volumes of claims. The results show that the populations are similar to the frequencies predicted by Benford\u27s Law. The findings also suggested possible fraudulent activity by specific providers, however, the companies determined that these results occurred due to abnormal billing practices and were not fraudulent. The insurance companies that participated in this study will continue to use this method to further detect fraudulent claims

Internal Auditor Participation in Systems Development Projects

There are differing viewpoints in the internal auditing literature regarding the role of internal audit in systems development projects. One argument is that internal audit should act as consultants for such projects. A counter argument is that if internal auditors act as consultants this could impair in dependence. This study surveyed chief audit executives to determine their perceptions of the role of internal audit in systems development projects as well as the actual involvement of their departments in such projects. The findings show that chief audit executives place more importance on internal audit acting as consultants and less importance on independence in these projects. The results also suggest that internal audit has limited involvement in the different phases of the Systems Development Life Cycle of these projects

Going-Concern Opinions: Broadening the Expectations Gap

A rash of high-profile bankruptcies has led to a search for answers. Many hold auditors responsible for not detecting the potential for bankruptcy during the most recent audit. The Weiss Report, a study of several dozen bankrupt companies submitted to the U.S. Senate during its deliberations on the Sarbanes-Oxley Act, found a broad and massive failure on the part of auditors to raise yellow flags that indicate potential bankruptcy. The authors examined Weiss\u27 methodology and found that, applied to a broader group of companies, Weiss\u27 criteria would have incorrectly predicted bankruptcy for nearly half of the non-bankrupt companies studied. This failure to accurately predict undermines the credibility of the subsequently enacted legislation

Using Benfords Law To Detect Fraud In The Insurance Industry

Benford's Law is the mathematical phenomena that states that the first digits or left most digits in a list of numbers will occur with an expected logarithmic frequency. While this method has been used in industries such as oil and gas and manufacturing to identify fraudulent activity, it has not been applied to the health insurance industry. Since health insurance companies process a large number of claims each year and these claims are susceptible to fraud, the use of this method in this industry is appropriate. This paper examines the application of Benford's Law to four health insurance companies located in the Midwest. For each company, analysis was performed on the first digit distribution, the first two-digit distribution, and providers with high volumes of claims. The results show that the populations are similar to the frequencies predicted by Benfords Law. The findings also suggested possible fraudulent activity by specific providers, however, the com-panies determined that these results occurred due to abnormal billing practices and were not frau-dulent. The insurance companies that participated in this study will continue to use this method to further detect fraudulent claims

Beyond a warming fingerprint: individualistic biogeographic responses to heterogeneous climate change in California.

Understanding recent biogeographic responses to climate change is fundamental for improving our predictions of likely future responses and guiding conservation planning at both local and global scales. Studies of observed biogeographic responses to 20th century climate change have principally examined effects related to ubiquitous increases in temperature - collectively termed a warming fingerprint. Although the importance of changes in other aspects of climate - particularly precipitation and water availability - is widely acknowledged from a theoretical standpoint and supported by paleontological evidence, we lack a practical understanding of how these changes interact with temperature to drive biogeographic responses. Further complicating matters, differences in life history and ecological attributes may lead species to respond differently to the same changes in climate. Here, we examine whether recent biogeographic patterns across California are consistent with a warming fingerprint. We describe how various components of climate have changed regionally in California during the 20th century and review empirical evidence of biogeographic responses to these changes, particularly elevational range shifts. Many responses to climate change do not appear to be consistent with a warming fingerprint, with downslope shifts in elevation being as common as upslope shifts across a number of taxa and many demographic and community responses being inconsistent with upslope shifts. We identify a number of potential direct and indirect mechanisms for these responses, including the influence of aspects of climate change other than temperature (e.g., the shifting seasonal balance of energy and water availability), differences in each taxon's sensitivity to climate change, trophic interactions, and land-use change. Finally, we highlight the need to move beyond a warming fingerprint in studies of biogeographic responses by considering a more multifaceted view of climate, emphasizing local-scale effects, and including a priori knowledge of relevant natural history for the taxa and regions under study

Dietetics students’ construction of competence through assessment and placement experiences

Aim Competency standards are widely adopted as a framework to describe standards of performance required in the workplace. Little is known, however, about how students construct competence. This qualitative study aimed to explore how dietetics students ready to graduate construct the concept of competence and the role of assessment in developing professional competence. Methods A qualitative description was used to gather data from a convenience sample of students ready to graduate from universities with accredited dietetics programs across Australia (10 out of 15 at the time of the study). A total of 11 focus groups were conducted to explore perspectives of competence and experiences of ‘competency-based’ assessment. Data were audio-recorded, transcribed and analysed using a thematic analysis approach. Results A total of 81 (n = 81) participants across 10 universities representing 22% of total students participated in the focus groups. Themes revealed that: (i) there is no shared understanding of competence; (ii) current work placement experiences may not reflect current standards or workforce needs; (iii) assessment approaches may not fully support the development of competence; and (iv) the competent performance of supervising dietitians/clinical educators in the workplace influences the construction of competence. Conclusions There is a need to work towards a shared understanding of dietetic entry-level competence in the profession. ‘Work-based’ learning experiences may need to be modified to ensure students meet current competency standards. Practitioners involved in student supervision need to acknowledge the influential role they have in the development of the future workforce

Oligonucleotide Based Magnetic Bead Capture of Onchocerca volvulus DNA for PCR Pool Screening of Vector Black Flies

The absence of infective larvae of Onchocerca volvulus in the black fly vector of this parasite is a major criterion used to certify that transmission has been eliminated in a focus. This process requires screening large numbers of flies. Currently, this is accomplished by screening pools of flies using a PCR-based assay. The number of flies that may be included in each pool is currently limited by the DNA purification process to 50 flies for Latin American vectors and 100 flies for African vectors. Here, we describe a new method for DNA purification that relies upon a specific oligonucleotide to capture and immobilize the parasite DNA on a magnetic bead. This method permits the reliable detection of a single infective larva of O. volvulus in pools containing up to 200 individual flies. The method described here will dramatically improve the efficiency of pool screening of vector black flies, making the process of elimination certification easier and less expensive to implement

Design, Analysis and Testing of a Novel Mitral Valve for Transcatheter Implantation

Mitral regurgitation is a common mitral valve dysfunction which may lead to heart failure. Because of the rapid aging of the population, conventional surgical repair and replacement of the pathological valve are often unsuitable for about half of symptomatic patients, who are judged high-risk. Transcatheter valve implantation could represent an effective solution. However, currently available aortic valve devices are inapt for the mitral position. This paper presents the design, development and hydrodynamic assessment of a novel bi-leaflet mitral valve suitable for transcatheter implantation. The device consists of two leaflets and a sealing component made from bovine pericardium, supported by a self-expanding wireframe made from superelastic NiTi alloy. A parametric design procedure based on numerical simulations was implemented to identify design parameters providing acceptable stress levels and maximum coaptation area for the leaflets. The wireframe was designed to host the leaflets and was optimised numerically to minimise the stresses for crimping in an 8 mm sheath for percutaneous delivery. Prototypes were built and their hydrodynamic performances were tested on a cardiac pulse duplicator, in compliance with the ISO5840-3:2013 standard. The numerical results and hydrodynamic tests show the feasibility of the device to be adopted as a transcatheter valve implant for treating mitral regurgitation

Phenotypic Complexity, Measurement Bias, and Poor Phenotypic Resolution Contribute to the Missing Heritability Problem in Genetic Association Studies

Background The variance explained by genetic variants as identified in (genome-wide) genetic association studies is typically small compared to family-based heritability estimates. Explanations of this ‘missing heritability’ have been mainly genetic, such as genetic heterogeneity and complex (epi-)genetic mechanisms. Methodology We used comprehensive simulation studies to show that three phenotypic measurement issues also provide viable explanations of the missing heritability: phenotypic complexity, measurement bias, and phenotypic resolution. We identify the circumstances in which the use of phenotypic sum-scores and the presence of measurement bias lower the power to detect genetic variants. In addition, we show how the differential resolution of psychometric instruments (i.e., whether the instrument includes items that resolve individual differences in the normal range or in the clinical range of a phenotype) affects the power to detect genetic variants. Conclusion We conclude that careful phenotypic data modelling can improve the genetic signal, and thus the statistical power to identify genetic variants by 20-99

Italian guidelines for primary headaches: 2012 revised version

The first edition of the Italian diagnostic and therapeutic guidelines for primary headaches in adults was published in J Headache Pain 2(Suppl. 1):105–190 (2001). Ten years later, the guideline committee of the Italian Society for the Study of Headaches (SISC) decided it was time to update therapeutic guidelines. A literature search was carried out on Medline database, and all articles on primary headache treatments in English, German, French and Italian published from February 2001 to December 2011 were taken into account. Only randomized controlled trials (RCT) and meta-analyses were analysed for each drug. If RCT were lacking, open studies and case series were also examined. According to the previous edition, four levels of recommendation were defined on the basis of levels of evidence, scientific strength of evidence and clinical effectiveness. Recommendations for symptomatic and prophylactic treatment of migraine and cluster headache were therefore revised with respect to previous 2001 guidelines and a section was dedicated to non-pharmacological treatment. This article reports a summary of the revised version published in extenso in an Italian version