Fraud Detection in Health Insurance Using Expert Re-referencing

Fraud is widespread and very costly to the healthcare insurance system. Fraud involves intentional deception or misrepresentation intended to result in an unauthorized benefit. It is shocking because the incidence of health insurance fraud keeps increasing every year. In order to detect and avoid the fraud, data mining techniques are applied. Frauds blow a hole in the insurance industry. Health insurance is a bleeding sector with very high claims ratio. So, to make health insurance industry free from fraud, it is necessary to focus on elimination or minimization of fake claims arriving through health insurance. Here, supervised and unsupervised techniques is employed to detect fraudulent claims along with expert re-referencing is also employed to detect claims efficiently. Keywords—data mining, fraud, health insurance fraud, supervised, unsupervised