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Application of Clustering Methods to Health Insurance Fraud Detection

Authors: Yi Peng; Gang Kou; Alan Sabatka; Zhengxin Chen; Deepak Khazanchi; Yong Shi;

Application of Clustering Methods to Health Insurance Fraud Detection

Abstract

Health insurance fraud detection is an important and challenging task. Traditionally, insurance companies use human inspections and heuristic rules to detect fraud. As the size of databases increases, the traditional approaches may miss a great portion of fraud for two main reasons. First, it is impossible to detect all health care fraud by manual inspection over large databases. Second, new types of health care fraud emerge constantly. SQL operations based on heuristic rules cannot identify those new emerging fraud schemes. Such a situation demands more sophisticated analytical methods and techniques that are capable of detecting fraud activities from large databases. The goal of this paper is to understand and detect suspicious health care frauds from large databases using clustering technique. Specifically, this paper applies two clustering methods, SAS EM and CLUTO, to a large real-life health insurance dataset and compares the performances of these two methods.

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selected citations
These citations are derived from selected sources.
This is an alternative to the "Influence" indicator, which also reflects the overall/total impact of an article in the research community at large, based on the underlying citation network (diachronically).
BIP!Citations provided by BIP!
popularity
This indicator reflects the "current" impact/attention (the "hype") of an article in the research community at large, based on the underlying citation network.
BIP!Popularity provided by BIP!
influence
This indicator reflects the overall/total impact of an article in the research community at large, based on the underlying citation network (diachronically).
BIP!Influence provided by BIP!
impulse
This indicator reflects the initial momentum of an article directly after its publication, based on the underlying citation network.
BIP!Impulse provided by BIP!
18
Top 10%
Top 10%
Average
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