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2006

A Medical Claim Fraud/Abuse Detection System based on Data Mining: A Case Study in Chile

11 years 1 months ago
A Medical Claim Fraud/Abuse Detection System based on Data Mining: A Case Study in Chile
This paper describes an effective medical claim fraud/abuse detection system based on data mining used by a Chilean private health insurance company. Fraud and abuse in medical claims have become a major concern within health insurance companies in Chile the last years due to the increasing losses in revenues. Processing medical claims is an exhausting manual task carried out by a few medical experts who have the responsibility of approving, modifying or rejecting the subsidies requested within a limited period from their reception. The proposed detection system uses one committee of multilayer perceptron neural networks (MLP) for each one of the entities involved in the fraud/abuse problem: medical claims, affiliates, medical professionals and employers. Results of the fraud detection system show a detection rate of approximately 75 fraudulent and abusive cases per month, making the detection 6.6 months earlier than without the system. The application of data mining to a real industri...
Pedro A. Ortega, Cristián J. Figueroa, Gonz
Added 30 Oct 2010
Updated 30 Oct 2010
Type Conference
Year 2006
Where DMIN
Authors Pedro A. Ortega, Cristián J. Figueroa, Gonzalo A. Ruz
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