Fraud Detection for Healthcare
نویسندگان
چکیده
Fraud detection in healthcare is an important yet difficult problem. We present a fraud screening solution to identify suspicious pharmacies from a large dataset of pharmacy claims. Our solution has stemmed from collaboration with medical claim investigators and proven usefulness to investigators by discovering real fraud cases. We focus on a concrete problem of probabilistic outlier detection from a feature set designed for pharmacy claims. Although the reported results are specific to pharmacy claims, this approach can be applied widely. We are currently extending the solution to fraud screening of more general medical claims and fraud detection in other verticals.
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