Provider response to cost containment: fraud & abuse issues.

Predicting Workers’ Compensation Insurance Fraud Using SAS Enterprise Miner 5.1 and SAS Text Miner

Insurance fraud costs the property and casualty insurance industry over 25 billion dollars (USD) annually. This paper addresses workers' compensation claim fraud. A data mining approach is adopted, and issues of data preparation are discussed. The focus is on building predictive models to score an open claim for a propensity to be fraudulent. A key component to modeling is the use of textual da...

Provider response to cost containment: an insider perspective.

Credit Card Fraud Detection using Data mining and Statistical Methods

Due to today’s advancement in technology and businesses, fraud detection has become a critical component of financial transactions. Considering vast amounts of data in large datasets, it becomes more difficult to detect fraud transactions manually. In this research, we propose a combined method using both data mining and statistical tasks, utilizing feature selection, resampling and cost-...

The Role of Controlled - Release Opioids in the Treatment of Chronic Pain

Conventional wisdom in the field of pain management assumes that controlled-release formulations of opioid analgesics provide superior pain control, and are less prone to abuse than immediaterelease formulations. Lack of evidence to support these assumptions is noted, and the issues of respective cost, convenience, efficacy, adherence, and abuse liability are analyzed. A clinical approach is pr...

No Evidence of the Effect of the Interventions to Combat Health Care Fraud and Abuse: A Systematic Review of Literature

BACKGROUND Despite the importance of health care fraud and the political, legislative and administrative attentions paid to it, combating fraud remains a challenge to the health systems. We aimed to identify, categorize and assess the effectiveness of the interventions to combat health care fraud and abuse. METHODS The interventions to combat health care fraud can be categorized as the interv...