An Intelligent Data Mining System to Detect Healthcare Fraud

An Intelligent Data Mining System to Detect Healthcare Fraud

Guisseppi A. Forgionne (University of Maryland Baltimore County, USA), Aryya Gangopadhyay (University of Maryland Baltimore County, USA) and Monica Adya (University of Maryland Baltimore County, USA)
Copyright: © 2000 |Pages: 20
DOI: 10.4018/978-1-878289-62-9.ch007
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Abstract

There are various forms of fraud in the health care industry. This fraud has a substantial financial impact on the cost of providing healthcare. Money wasted on fraud will be unavailable for the diagnosis and treatment of legitimate illnesses. The rising costs of and the potential adverse affects on quality healthcare have encouraged organizations to institute measures for detecting fraud and intercepting erroneous payments. Current fraud detection approaches are largely reactive in nature. Fraud occurs, and various schemes are used to detect this fraud afterwards. Corrective action then is instituted to alleviate the consequences. This chapter presents a proactive approach to detection based on artificial intelligence methodology. In particular, we propose the use of data mining and classification rules to determine the existence or non-existence of fraud patterns in the available data. The chapter begins with an overview of the types of healthcare fraud. Next, there is a brief discussion of issues with the current fraud detection approaches. The chapter then develops information technology based approaches and illustrates how these technologies can improve current practice. Finally, there is a summary of the major findings and the implications for healthcare practice.

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Table of Contents
Preface
Adi Armoni
Chapter 1
Anita Krabbel, Ingrid Wetzel
Anyone working in the area of hospital information systems is sooner or later amazed about the intrinsic complexity of the field. Finding ways to... Sample PDF
Designing Hospital Information Systems: Handling Complexity via a User-Oriented, Document-Based Approach
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Chapter 2
Minh Huynh, Sal Agnihothri
In this chapter, we present key principles and the limitations of business process reengineering (BPR) in general, and the use of BPR in healthcare... Sample PDF
Healthcare Process Redesign: A Case Study
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Chapter 3
Lech J. Janczewski
This chapter outlines the major issues related to the security of medical information systems. Medical information systems are unique in this sense... Sample PDF
Information Security Framework for Health Information Systems
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Chapter 4
Felix B. Tan, Gehan Gunasekara
The chapter reports on recent developments in the management of health information in New Zealand and the implications these initiatives have raised... Sample PDF
Health Information Management and Individual Privacy: Application of New Zealand's Privacy Legislation
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Chapter 5
Richard Heeks, David Mundy, Angel Salazar
Some health care information systems (HCIS) do succeed, but the majority are likely to fail in some way. To explain why this happens, and how... Sample PDF
Understanding Success and Failure of Healthcare Information Systems
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Chapter 6
Adi Armoni
In recent years we have witnessed sweeping developments in information technology. Currently, the most promising and interesting domain seemed to be... Sample PDF
The Use of Artificial Intelligence Techniques and Applications in the Medical Domain
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Chapter 7
Guisseppi A. Forgionne, Aryya Gangopadhyay, Monica Adya
There are various forms of fraud in the health care industry. This fraud has a substantial financial impact on the cost of providing healthcare.... Sample PDF
An Intelligent Data Mining System to Detect Healthcare Fraud
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Chapter 8
Adi Armoni
The article examines the behavior of the human decision-maker. It surveys research in which about 90 physicians specializing in various fields and... Sample PDF
Diabetes Mellitus - Evaluating the Diagnostic Probabilities
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Chapter 9
Bruno Lavi, Zeev Rothstein
Health systems broaden their importance in the midst of the ongoing international communications revolution. Health services are a natural candidate... Sample PDF
Telemedicine and the Information Highway
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Chapter 10
Mahesh S. Raisinghani, Ann Shou-an Char
Client-server architecture is a local area network (LAN) based computing environment in which a central database sever or engine performs all... Sample PDF
Client-Server Computing: Lessons Learned and an Application in the Healthcare Industry
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About the Authors