ORGANIZED HEALTHCARE FRAUD DETECTION
First Claim
1. A method, comprising:
- receiving, by one or more devices of a fraud detection system, information that identifies healthcare claims associated with providers and beneficiaries;
determining, by the one or more devices and based on the healthcare claims, first fraud sets associated with postulated classes of fraud;
determining, by the one or more devices and based on the healthcare claims, second fraud sets using a data mining technique;
calculating, by the one or more devices, probabilities that the first fraud sets and the second fraud sets are similar to no fraud observations;
ranking, by the one or more devices, the first fraud sets and the second fraud sets based on the calculated probabilities; and
outputting, by the one or more devices, a ranked list of suspected fraud cases, associated with the healthcare claims, based on the ranking of the first fraud sets and the second fraud sets.
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Accused Products
Abstract
A fraud detection system receives information that identifies healthcare claims associated with providers and beneficiaries, and determines, based on the healthcare claims, first fraud sets associated with postulated classes of fraud. The fraud detection system determines, based on the healthcare claims, second fraud sets using one or more data mining techniques, and calculates probabilities that the first fraud sets and the second fraud sets are similar to no fraud observations. The fraud detection system ranks the first fraud sets and the second fraud sets based on the calculated probabilities, and outputs a ranked list of suspected fraud cases, associated with the healthcare claims, based on the ranking of the first fraud sets and the second fraud sets.
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Citations
20 Claims
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1. A method, comprising:
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receiving, by one or more devices of a fraud detection system, information that identifies healthcare claims associated with providers and beneficiaries; determining, by the one or more devices and based on the healthcare claims, first fraud sets associated with postulated classes of fraud; determining, by the one or more devices and based on the healthcare claims, second fraud sets using a data mining technique; calculating, by the one or more devices, probabilities that the first fraud sets and the second fraud sets are similar to no fraud observations; ranking, by the one or more devices, the first fraud sets and the second fraud sets based on the calculated probabilities; and outputting, by the one or more devices, a ranked list of suspected fraud cases, associated with the healthcare claims, based on the ranking of the first fraud sets and the second fraud sets. - View Dependent Claims (2, 3, 4, 5, 6, 7)
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8. A fraud detection system, comprising:
one or more processors to; receive information that identifies healthcare claims associated with providers and beneficiaries, determine, based on the healthcare claims, first fraud sets associated with postulated classes of fraud, determine, based on the healthcare claims, second fraud sets using one or more data mining techniques, calculate probabilities that the first fraud sets and the second fraud sets are similar to no fraud observations, rank the first fraud sets and the second fraud sets based on the calculated probabilities, and output or store a ranked list of suspected fraud cases, associated with the healthcare claims, based on the ranking of the first fraud sets and the second fraud sets. - View Dependent Claims (9, 10, 11, 12, 13, 14)
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15. One or more computer-readable media, comprising:
one or more instructions that, when executed by one or more processors of a fraud detection system, cause the one or more processors to; receive information that identifies healthcare claims associated with providers and beneficiaries, determine, based on the healthcare claims, first fraud sets associated with postulated classes of fraud, determine, based on the healthcare claims, second fraud sets using one or more data mining techniques, calculate probabilities that the first fraud sets and the second fraud sets are similar to no fraud observations, rank the first fraud sets and the second fraud sets based on the calculated probabilities, and output a ranked list of suspected fraud cases, associated with the healthcare claims, based on the ranking of the first fraud sets and the second fraud sets. - View Dependent Claims (16, 17, 18, 19, 20)
Specification