Classification in the Detection of Health Care Fraud and Abuse

1. Classification in the Detection of Health Care Fraud and Abuse 2004/10/21

2. Outline • NHI program in Taiwan • BNHI • Health care fraud and abuse problem • Detection approach • Feature selection • Classification • Detection result

3. NHI program in Taiwan • The National Health Insurance (NHI) program: • Developed in 1995 • Administered by the Bureau of National Health Insurance (BNHI). • Provide the public comprehensive medical care • More than 21 million individuals are enrolled in the program (with coverage rate 96%) • More than 92% health institutions are contacted in the program

4. NHI program in Taiwan • The Fee-for-Service payment method is mainly used between 1995 to 2001. • Fee-application process • Hence, reviewing hospitals’ applications becomes an important work for BNHI

5. Detection approach • Common health care fraud and abuse: • Billing services that are never rendered, • Performing more expensive services, • Performing unnecessary medical services, • Misrepresenting non-covered treatments as necessary covered treatments, • Falsification of patients diagnosis/treatment history.

6. Detection approach • Since health care fraud and abuse often result in unauthorized benefit, indicators derived from expense may have the detection power.

7. Detection approach • Model development • Data are collected from a regional-level hospital between July 2001 to June 2002, • 906 normal PID instances are collected, • 906 fraudulent PID instances are also collected, • ID3 (C4.5) algorithm is used to construct decision rules.

8. Detection approach