WMTDBC: An unsupervised multivariate analysis model for fraud detection in health insurance claims

Settipalli, Lavanya; Gangadharan, G. R.

doi:10.1016/j.eswa.2022.119259

Cited by 16 publications

(2 citation statements)

References 34 publications

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“…Kapadiya et al ( 17 ) developed a blockchain-based model for the secure sharing of healthcare data and detecting fraudulent transactions. Moreover, Settipalli and Gangadharan ( 18 ) proposed an unsupervised multivariate analysis model for detecting Medicare fraud and demonstrated its effectiveness. Bauder and Khoshgoftaar ( 19 ) explored the challenges of imbalanced big data in Medicare fraud detection and provided insights into addressing the class imbalance.…”

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confidence: 99%

A study on the path of governance in health insurance fraud considering moral hazard

Liu,

Wang,

2023

Front. Public Health

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Combating health insurance fraud is of utmost importance to physicians, patients, and health insurers. To delve into the mechanisms of health insurance fraud between doctors and patients, this study employed evolutionary game theory to construct a model that comprehensively considers moral hazard, fraud cost, reward, punishment, bribes from patients, and other factors. Through theoretical analysis and numerical simulation of the model, the study discovered that the evolution of governance behavior in health insurance fraud is closely linked to its initial construction of the payment matrix and the initial selection of parameters for the payment matrix. Additionally, increasing penalties for fraudulent behavior, increasing the cost of fraud for both doctors and patients, and reducing moral hazard for both can effectively drive the final strategy of the system toward a non-fraudulent state. The study aims to provide valuable insights and recommendations to doctors, patients, and medical insurance institutions in establishing a sound governance environment for managing fraud behavior in health insurance.

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Section: Introductionmentioning

confidence: 99%

A study on the path of governance in health insurance fraud considering moral hazard

Liu,

Wang,

2023

Front. Public Health

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“…In the United States, medical insurance fraud results in tens of billions of dollars in losses each year [ 4 , 5 ]. In India, medical insurance fraud accounts for about 15% of total claims [ 6 ], and in China, medical insurance fraud accounts for about 7–8% of national healthcare costs [ 7 ]. Therefore, there is an urgent need to combat medical insurance fraud.…”

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confidence: 99%

What are people’s attitudes toward medical insurance fraud whistleblowers? a study from China

Chen,

Deng,

et al. 2024

BMC Public Health

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Purpose Medical insurance fraud has caused huge losses to countries around the world, and public reporting has become an important means to combat medical insurance fraud. The attitude of medical insurance fraud whistleblowers affects people’s reporting behavior, and understanding people’s attitude toward medical insurance fraud whistleblowers provides a basis for further improving the system and policy of public participation in medical insurance fund supervision. Methods We adopted the questionnaire method to conduct a national cross-sectional survey of the Chinese public and analyzed the data using Chi-square tests, Fisher’s exact tests, and binary logistic regression models. Results A total of 837 respondents were included, and 81.8% of the population had a supportive attitude toward medical insurance fraud whistleblowers, with gender, whether they had used medical insurance reimbursement, and present life satisfaction being statistically significant (P < 0.05). Conclusion The public is generally supportive of medical insurance fraud whistleblowers, and women, those who have used medical insurance for reimbursement, and those who are satisfied with their lives are more likely to be supportive of medical insurance fraud whistleblowers.

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Design and development of big data-based model for detecting fraud in healthcare insurance industry

Mary

Claret

2023

Soft Comput

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WMTDBC: An unsupervised multivariate analysis model for fraud detection in health insurance claims

Cited by 16 publications

References 34 publications

A study on the path of governance in health insurance fraud considering moral hazard

A study on the path of governance in health insurance fraud considering moral hazard

What are people’s attitudes toward medical insurance fraud whistleblowers? a study from China

Design and development of big data-based model for detecting fraud in healthcare insurance industry

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