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Fraud Detection for Healthcare
Conferences & Talks
11 August 2013
Fraud detection in healthcare is an important yet dificult 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 specifi c to pharmacy claims, this work is not restricted to pharmacy claims. We are currently extending the solution to fraud screening of more general medical claims and fraud detection in other verticals.
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