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Health insurance fraud detection based on multi-channel heterogeneous graph structure learning [PDF]

Heliyon
Health insurance fraud is becoming more common and impacting the fairness and sustainability of the health insurance system. Traditional health insurance fraud detection primarily relies on recognizing established data patterns.
Binsheng Hong, Ping Lu, Hang Xu, Jiangtao Lu, Kaibiao Lin, Fan Yang   +5 more
doaj   +3 more sources

What are people’s attitudes toward medical insurance fraud whistleblowers? a study from China [PDF]

BMC Public Health
Purpose Medical insurance fraud has caused huge losses to countries around the world, and public reporting has become an important means to combat medical insurance fraud.
Fangting Chen, Fangmin Deng, Jingran He, Jinpeng Xu, Jian Liu, Qi Shi, Hongyu Zhang, Ting Zhang, Qunhong Wu, Lijun Gao, Guomei Tian, Zheng Kang   +11 more
doaj   +3 more sources

A study on the path of governance in health insurance fraud considering moral hazard [PDF]

Frontiers in Public Health, 2023
Combating health insurance fraud is of utmost importance to physicians, patients, and health insurers. To delve into the mechanisms of health insurance fraud between doctors and patients, this study employed evolutionary game theory to construct a model ...
Jusheng Liu, Yuan Wang, Jiali Yu
doaj   +3 more sources

Automatic Recommender System of Development Platforms for Smart Contract–Based Health Care Insurance Fraud Detection Solutions: Taxonomy and Performance Evaluation

Journal of Medical Internet Research, 2023
BackgroundHealth care insurance fraud is on the rise in many ways, such as falsifying information and hiding third-party liability. This can result in significant losses for the medical health insurance industry.
Rima Kaafarani, Leila Ismail, Oussama Zahwe   +2 more
doaj   +3 more sources

What influences the public’s willingness to report health insurance fraud in familiar or unfamiliar healthcare settings? a cross-sectional study of the young and middle-aged people in China [PDF]

BMC Public Health
Introduction Young and middle-aged people are important participants in the fight against health insurance fraud. The study aims to investigate the differences in their willingness to report health insurance fraud and the factors influencing it when it ...
Jinpeng Xu, Ting Zhang, Hongyu Zhang, Fangmin Deng, Qi Shi, Jian Liu, Fangting Chen, Jingran He, Qunhong Wu, Zheng Kang, Guomei Tian   +10 more
doaj   +3 more sources

Health insurance fraud detection by using an attributed heterogeneous information network with a hierarchical attention mechanism [PDF]

BMC Medical Informatics and Decision Making, 2023
Background With the rapid growth of healthcare services, health insurance fraud detection has become an important measure to ensure efficient use of public funds.
Jiangtao Lu, Kaibiao Lin, Ruicong Chen, Min Lin, Xin Chen, Ping Lu   +5 more
doaj   +3 more sources

Healthcare insurance fraud detection using data mining [PDF]

BMC Medical Informatics and Decision Making
Background Healthcare programs and insurance initiatives play a crucial role in ensuring that people have access to medical care. There are many benefits of healthcare insurance programs but fraud in healthcare continues to be a significant challenge in ...
Zain Hamid, Fatima Khalique, Saba Mahmood, Ali Daud, Amal Bukhari, Bader Alshemaimri   +5 more
doaj   +3 more sources

A robust and interpretable ensemble machine learning model for predicting healthcare insurance fraud. [PDF]

Sci Rep
Healthcare insurance fraud imposes a significant financial burden on healthcare systems worldwide, with annual losses reaching billions of dollars. This study aims to improve fraud detection accuracy using machine learning techniques.
Wang Z, Chen X, Wu Y, Jiang L, Lin S, Qiu G.   +5 more
europepmc   +2 more sources

Insurance claims estimation and fraud detection with optimized deep learning techniques [PDF]

Scientific Reports
Estimation and fraud detection in the case of insurance claims play a cardinal role in the insurance sector. With accurate estimation of insurance claims, insurers can have good risk perceptions and disburse compensation within proper time, while fraud ...
P. Anand Kumar, S. Sountharrajan
doaj   +3 more sources

Fourteen years of manifestations and factors of health insurance fraud, 2006–2020: a scoping review [PDF]

Health & Justice, 2021
Background Healthcare fraud entails great financial and human losses; however, there is no consensus regarding its definition, nor is there an inventory of its manifestations and factors.
José Villegas-Ortega, Luciana Bellido-Boza, David Mauricio   +2 more
doaj   +2 more sources