Weighted risk models for dynamic healthcare fraud detection. Issue 2 (9th June 2021)

• Record Type: Journal Article
• Authors: Rolfe, Alyssa J.
• Is Part Of: Risk management and insurance review. Volume 24:Issue 2(2021)
• Page Start: 143
• Page End: 150
• Publication Date: 2021-06-09
• Subjects: Risk (Insurance) -- Periodicals; Risk management -- Periodicals; Risk (Insurance) -- United States -- Periodicals; Risk management -- United States -- Periodicals; 368
• DOI: 10.1111/rmir.12183
• Languages: English
• ISSNs: 1098-1616

Abstract

Abstract: Despite efforts to prevent it, fraud in the United States healthcare system remains a serious and pressing issue. Since healthcare fraud is a complex and multi‐faceted problem, fraud‐fighting solutions must be flexible enough to address the ever‐evolving nature of the crime. Here, we present a method to identify healthcare fraud in such a manner that incorporates both potential fraud as well as risky provider behavior. The proposed weighted risk model provides a framework for creating a dynamic fraud detection database that can be easily scaled up to incorporate emerging fraud schemes.