Outlier detection in healthcare fraud: A case study in the Medicaid dental domain
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- 作者：Guido van Capelleveena ; 1 ; g.c.vancapelleveen@utwente.nl" class="auth_mail" title="E-mail the corresponding author ; Mannes Poelb ; 1 ; m.poel@utwente.nl" class="auth_mail" title="E-mail the corresponding author ; Roland M. Muellera ; c ; 2 ; roland.mueller@hwr-berlin.de" class="auth_mail" title="E-mail the corresponding author ; Dallas Thorntona ; d ; 3 ; dallas@clemson.edu" class="auth_mail" title="E-mail the corresponding author ; Jos van Hillegersberga ; j.vanhillegersberg@utwente.nl" class="auth_mail" title="E-mail the corresponding author
- 关键词：Medical fraud detection ; Decision support ; Outlier detection
- 刊名：International Journal of Accounting Information Systems
- 出版年：2016
- 出版时间：June 2016
- 年：2016
- 卷：21
- 期：Complete
- 页码：18-31
- 全文大小：1287 K
文摘
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A case study of fraud analysis using was performed on Medicaid claims of 369 primary dental providers of one state
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Examples of strong cases of potential fraud schemes detected are presented and discussed
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Outlier detection can be utilized in automatic detection systems and may identify new patterns of potential healthcare fraud
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Healthcare subject matter expertise or claim documentation remain important when classifying claim patterns as fraudulent