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Predicting Healthcare Fraud in Medicaid: A Multidimensional Data Model and Analysis Techniques for Fraud Detection

机译:预测医疗补助中的医疗欺诈:用于欺诈检测的多维数据模型和分析技术

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摘要

It is estimated that approximately $700 billion is lost due to fraud, waste, and abuse in the US healthcare system. Medicaid has been particularly susceptible target for fraud in recent years, with a distributed management model, limited cross- program communications, and a difficult-to-track patient population of low-income adults, their children, and people with certain disabilities. For effective fraud detection, one has to look at the data beyond the transaction-level. This paper builds upon Sparrow's fraud type classifications and the Medicaid environment and to develop a Medicaid multidimensional schema and provide a set of multidimensional data models and analysis techniques that help to predict the likelihood of fraudulent activities. These data views address the most prevalent known fraud types and should prove useful in discovering the unknown unknowns. The model is evaluated by functionally testing against known fraud cases
机译:据估计,由于美国医疗保健系统中的欺诈,浪费和滥用,大约损失了7,000亿美元。近年来,医疗补助特别容易成为欺诈的目标,其分布式的管理模式,有限的跨程序通信以及难以跟踪的低收入成年人,其子女和某些残疾人的患者群体。为了有效地检测欺诈,必须查看交易级别之外的数据。本文基于Sparrow的欺诈类型分类和Medicaid环境,并开发了Medicaid多维模式,并提供了一组多维数据模型和分析技术,可帮助预测欺诈活动的可能性。这些数据视图可解决最普遍的已知欺诈类型,并应证明对发现未知未知数很有用。通过对已知欺诈案件进行功能测试来评估模型

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