A Framework for Fraud Detection in Government Supported National Healthcare Programs
Irum Matloob, Shoab Ahmed Khan · 2019
Fraud, waste and abuse have created prominent cost overruns in health care sector for the last few decades. There is a critical need of fraud detection system to control and monitor health insurance claims specially in developing countries. In many developing countries, governments have initiated various programs in which states take the responsibility to bear cost of medical services consumed by under privileged class. The paper proposed a framework for detecting fraudulent insurance claims by creating time series, traces of every transaction to identify invalid procedures and claims. The proposed framework is evaluated for different types of anomalies like age based anomaly, gender based, service providing pattern based and service availing pattern-based anomalies, on local hospital transactional data. The detection and monitoring of fraud is necessary to increase the quality and efficiency of healthcare.