Health insurance is important for many people, but unfortunately it is susceptible to frauds, therefore expenditures for covering the funds show exponential growth. The victims of this kind of scams are not only the institutions that provide the funds and treatments, but also are the ones who ...
You can saygeneral medical billing frauds in healthcare practicesare the same as other industry frauds and fraudsters are always looking for an opportunity to take full advantage to unjustly profit. However, every stakeholder in the healthcare system should avoid fraudulent behavior to avoid further ...
These frauds cause a significant loss to the insurance fund and threaten its normal operation. Measures should be taken to detect and report fraud, waste, and abuse in the system, including errors and abuse by providers, unnecessary costs to the payer, and exploitation of weaknesses in internal...
The Fig.1explains the most popular classification of the frauds in healthcare insurance system. Fraud can be identified through the services availing as well as providing patterns. Availing patterns such as repetition of services, age inconsistency, gender inconsistency, and visit frequency can leads...
19Major Pharmaceutical Frauds: Deep Pockets and Low-Hanging FruitPharmaceutical firms are among the world’s wealthiest corporations. By July 2008, the ten largest pharmaceutical companies in the United States had annual PHARMACEUTICAL, EQUIPMENT, AND SUPPLY INDUSTRIES 121revenues ranging from $20.2 ...
In addition, the United States Federal Trade Commission warns customers to prevent frauds of coronaviruses, such as disregarding online test kits and vaccine promises. Consumers need to be effectively safeguarded against counterfeit home surveillance equipment. The General Public Prosecutor should actively...
To combat these frauds, 160 agents are specifically responsible for carrying out checks a priori, when the application is made, and a posteriori [35]. According to the “Caisse Nationale d’Assurance Maladie” – National Fund Health Insurance, 54 fraudulent applications were detected in 2014, ...
In summary, in the existing researches, the common methods for intelligently identifying medical insurance frauds using data mining algorithms are machine learning, neural networks, integrated learning, etc., and have achieved certain research results [30]. However, many of the researches are theoretica...
Ortega [7] designed a system which applied multi-layer perceptron neural networks on the data of Chilean private health insurance company to detect the fraudulent activities; the detection rate of this system is 75 frauds per month. Another framework is proposed [8], which introduced an adaptable...