Behavior-Based Anomaly Detection

ABSTRACT:

Conservative estimates of provider fraud (and abuse) - that is, fraud committed by doctors and other care givers - range between 10% and 12% of the roughly $650 billion spent annually on healthcare in the United States.  Given the enormous amounts of money involved in the American healthcare industry, the shallowness of the regulatory oversight, the complexity of today's medical service protocols, and the relative ease with which abusive behaviors can be disguised or buried in the high transaction volumes processed by most insurers, it is easy to understand how abusive and ultimately fraudulent behavior can arise.  Managed healthcare fraud is further complicated by the fragmentary nature of the patterns themselves - claims are dispersed across time and across many different insurance companies often renamed and defined according to different medical protocols so that no single insurer or oversight agency has a complete picture of a provider's activities.

The difficulty in detecting managed healthcare fraud is generally compounded by... 

Download the White Paper