Application of clustering methods to health insurance fraud detection

Yi Peng, Gang Kou, Alan Sabatka, Zhengxin Chen, Deepak Khazanchi, Yong Shi

Research output: Chapter in Book/Report/Conference proceedingConference contribution

11 Scopus citations

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.

Original languageEnglish (US)
Title of host publicationProceedings - ICSSSM'06
Subtitle of host publication2006 International Conference on Service Systems and Service Management
PublisherIEEE Computer Society
Pages116-120
Number of pages5
ISBN (Print)1424404517, 9781424404513
DOIs
StatePublished - 2006
EventICSSSM'06: 2006 International Conference on Service Systems and Service Management - Troyes, France
Duration: Oct 25 2006Oct 27 2006

Publication series

NameProceedings - ICSSSM'06: 2006 International Conference on Service Systems and Service Management
Volume1

Conference

ConferenceICSSSM'06: 2006 International Conference on Service Systems and Service Management
CountryFrance
CityTroyes
Period10/25/0610/27/06

Keywords

  • Clustering
  • Database
  • Insurance fraud detection

ASJC Scopus subject areas

  • Tourism, Leisure and Hospitality Management

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  • Cite this

    Peng, Y., Kou, G., Sabatka, A., Chen, Z., Khazanchi, D., & Shi, Y. (2006). Application of clustering methods to health insurance fraud detection. In Proceedings - ICSSSM'06: 2006 International Conference on Service Systems and Service Management (pp. 116-120). [4114418] (Proceedings - ICSSSM'06: 2006 International Conference on Service Systems and Service Management; Vol. 1). IEEE Computer Society. https://doi.org/10.1109/ICSSSM.2006.320598