إظهار الرسائل ذات التسميات Medical Claim. إظهار كافة الرسائل
إظهار الرسائل ذات التسميات Medical Claim. إظهار كافة الرسائل
الأحد، 15 يونيو 2014
الجمعة، 13 يونيو 2014
الخميس، 12 يونيو 2014
الاثنين، 9 يونيو 2014
الجمعة، 14 مارس 2014
A Medical Claim Fraud/Abuse Detection System based on Data Mining: A Case Study in Chile
by Pedro A. Ortega
Abstract — This paper describes an effective medical claim fraud/abuse detection system based on data mining used by a Chilean private health insurance company. Fraud and abuse in medical claims have become a major concern within health insurance companies in Chile the last years due to the increasing losses in revenues. Processing medical claims is an exhausting manual task carried out by a few medical experts who have the responsibility of approving, modifying or rejecting the subsidies requested within a limited period from their reception. The proposed detection system uses one committee of multilayer perceptron neural networks (MLP) for each one of the entities involved in the fraud/abuse problem: medical claims, affiliates, medical professionals and employers. Results of the fraud detection system show a detection rate of approximately 75 fraudulent and abusive cases per month, making the detection 6.6 months earlier than without the system. The application of data mining to a real industrial problem through the implementation of an automatic fraud detection system changed the original non-standard medical claims checking process to a standardized process helping to fight against new, unusual and known
fraudulent/abusive behaviors. I.
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