Fraud Detection in Healthcare

We discuss the problem of fraud detection in healthcare in this chapter. Given the recent scrutiny of the ineciencies in the US healthcare system, identifying fraud has been on the forefront of the eorts towards reducing the healthcare costs. In this chapter we will focus on understanding the issue of healthcare fraud in detail, and review methods that have been proposed in the literature to combat this issue using data driven approach.

[1]  Varun Chandola,et al.  Knowledge discovery from massive healthcare claims data , 2013, KDD.

[2]  Graham J. Williams,et al.  On-Line Unsupervised Outlier Detection Using Finite Mixtures with Discounting Learning Algorithms , 2000, KDD '00.

[3]  Michael Höhle,et al.  Online Change-Point Detection in Categorical Time Series , 2010 .

[4]  Ihsan Sabuncuoglu,et al.  A prescription fraud detection model , 2012, Comput. Methods Programs Biomed..

[5]  Rajeev Motwani,et al.  The PageRank Citation Ranking : Bringing Order to the Web , 1999, WWW 1999.

[6]  Wan-Shiou Yang,et al.  A Process Pattern Mining Framework for the Detection of Health Care Fraud and Abuse , 2003 .

[7]  Kelly Burnes Turning Information into Action , 2012 .

[8]  Douglas C. Montgomery,et al.  Introduction to Statistical Quality Control , 1986 .

[9]  Mark Newman,et al.  Networks: An Introduction , 2010 .

[10]  Ramakrishnan Srikant,et al.  Mining sequential patterns , 1995, Proceedings of the Eleventh International Conference on Data Engineering.

[11]  Jionghua Jin,et al.  A survey on statistical methods for health care fraud detection , 2008, Health care management science.

[12]  Vipin Kumar,et al.  Similarity Measures for Categorical Data: A Comparative Evaluation , 2008, SDM.

[13]  Charu C. Aggarwal,et al.  Outlier Analysis , 2013, Springer New York.

[14]  VARUN CHANDOLA,et al.  Anomaly detection: A survey , 2009, CSUR.

[15]  Hongxing He,et al.  Application of neural networks to detection of medical fraud , 1997 .

[16]  L. Weiss License to Steal: How Fraud Bleeds America's Health Care System , 2001 .

[17]  Dino Pedreschi,et al.  A classification-based methodology for planning audit strategies in fraud detection , 1999, KDD '99.

[18]  S. Preston,et al.  Low Life Expectancy in the United States: Is the Health Care System at Fault? , 2009 .

[19]  Pedro A. Ortega,et al.  A Medical Claim Fraud/Abuse Detection System based on Data Mining: A Case Study in Chile , 2006, DMIN.

[20]  Zachary G. Stoumbos,et al.  A CUSUM Chart for Monitoring a Proportion When Inspecting Continuously , 1999 .

[21]  Tom Fawcett,et al.  Activity monitoring: noticing interesting changes in behavior , 1999, KDD '99.

[22]  Jiawei Han,et al.  CloseGraph: mining closed frequent graph patterns , 2003, KDD '03.