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

The Potential Role of Spirituality in Conducting Field Research: Examination of a Model and a Process

The Cognitive-Experiential Tri-Circle is a model developed by the author to explain the relationship between conducting field research and reflecting on beliefs, including spiritual beliefs. His sample included graduate students, faculty, and friends of the university who participated in field research trips to Cuba through Loyola University Chicago. The basic assumption of the model is that self, beliefs, and experience are related in such a way that depth applies to each equally in a field research experience. Depth of experience for the self leads to depth of belief for the self . Reflection tools that encourage depth of belief for the self lead to depth of experience for the self. The author designed a particular method for processing or reflection which he used with participants on these trips. He al so discusses at length the philosophical issues involved in this topic. The paper concludes that the processing method was effective and that the model is applicable to field research experiences

An epigenetic approach to fatty acid metabolism in haematological malignancies

[eng] The role of fatty acids to overcome stress and contribute to disease progression is becoming increasingly evident in haematological diseases. Further, epigenetic factors play an important role in the aetiology of myelodysplastic syndromes (MDS) and the transformation to secondary acute myeloid leukaemia (sAML). To investigate this in the MDS/sAML cell line, SKK-1, we employed a shRNA knockdown screen to target 912 epigenetic regulators. We then coupled this loss-of-function approach to a fatty acid metabolism-based assay with which we were able to cell-sort the SKK-1 cells based on the fatty acid uptake. Here I describe the methodology of this epigenetics-metabolism approach and our efforts to validate candidate hits from the screen that were predicted to be modulators of fatty acid uptake. Following testing using single gene knockdowns of the top genes from the screen, we were not able to identify epigenetic regulators that significantly alter fatty acid uptake. In parallel, we characterised metabolic and genetic parameters of triple-sorted low (TS LOW) and high (TS HIGH) fatty acid uptake sub- populations. However, during the course of the study, we discovered latent contamination by another myeloid cell line, U-937, in our SKK-1 parental cells and TS LOW and TS HIGH sub-populations. Therefore, we interpreted results from the characterisation study with the knowledge that we had mixed cellular populations. I describe the steps we took to first identify the cell line and then our further characterisation of single cell clones of TS LOW and TS HIGH. Interestingly, we observed distinct cytogenetic profiles between single clones of TS LOW and TS HIGH, namely trisomy 8, which is a highly relevant chromosomal aberration in myeloid malignancies. Overall, this study provides a novel approach to investigate epigenetic and metabolic interactions in blood malignancies. We also find metabolically distinct sub-populations that differ by a disease-relevant karyotype

Exploring the factors that encourage postholders to engage in curriculum leadership. A study of large primary schools.

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