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from the Robert's-your-mother's-brother dept.
https://www.hcanews.com/news/how-machine-learning-could-detect-medicare-fraud
Machine learning could become a useful tool in helping to detect Medicare fraud, according to a new study, potentially reclaiming anywhere from $19 billion to $65 billion lost to fraud each year.
Researchers from Florida Atlantic University's College of Engineering and Computer Science recently published the world's first study using Medicare Part B data, machine learning and advanced analytics to automate fraud detection. They tested six different machine learners on balanced and imbalanced data sets, ultimately finding the RF100 random forest algorithm to be most effective at identifying possible instances of fraud. They also found that imbalanced data sets are more preferable than balanced data sets when scanning for fraud.
"There are so many intricacies involved in determining what is fraud and what is not fraud, such as clerical error," Richard A. Bauder, senior author and a Ph.D. student at the school, said. "Our goal is to enable machine learners to cull through all of this data and flag anything suspicious. Then we can alert investigators and auditors, who will only have to focus on 50 cases instead of 500 cases or more."
[...] "If we can predict a physician's specialty accurately based on our statistical analyses, then we could potentially find unusual physician behaviors and flag these as possible fraud for further investigation," Taghi M. Khoshgoftaar, Ph.D., co-author and a professor at the school, said.
So, if a cardiologist were incorrectly labeled a neurologist, that could be a sign of fraud.
Still, the data set itself remained a challenge. The small number of fraudulent providers and the large number of above-board providers made the data set imbalanced, which can fool machine learners. So, using random undersampling, investigators whittled down the set to 12,000 cases, with seven class distributions ranging from severely imbalanced to balanced.
[...] Surprisingly, researchers found that keeping the data set 90 percent normal and 10 percent fraudulent was the "sweet spot" for machine-learning algorithms tasked with identifying Medicare fraud. They thought the ratio would need to include more fraudulent providers for the learners to be effective.
Actually a compelling argument for single payer.
(Score: 0) by Anonymous Coward on Tuesday November 06 2018, @03:06PM
Worth noting that if you look up false claims act suites, something like 60% of them in recent history are against insurers. In regards to overbilling, there is a simple way to evaluate this. Devide the number of doctors by the number of billing clerks. A typical doctors office has a ratio of four billing clerks to every doctor. I have yet to figure out how it is possible to have 4 people spending 8 hours a day billing for what one man does in 4 hours a day. Unless of course it is wrangling with the perpetual fuckage that is the insurers.
I had a surgery some years back due to a car wreck. I had a 5K deductable zero copay (before obamacare eliminated zero copay policies) and 5K of injury on my vehicle. So I was 100% covered. I recieved a dozen bills, and one bill that was for shit that never happened. Then the health insurer, (Avant) balked on $2k of the bill, claiming overcharging. The doctor billed me the difference. I had to threaten to sue the fucker to get them to sort it out between them, though I never found out what the settlement was. All I got was a revised bill with a zero balance.
These games are rediculous. Insurers don't heal people. What they do is 100% overhead on the services and products provided. Further the state does not compel the insurers to disclose kickbacks. So what you are being billed is in no way reflective of what the doctor is actually charging. So if you're paying a 50% copay, part of that is being kicked back to the insurer, which means that you are paying much much more than 50%. If you consider the actual markup, and the likely margin between the insurer billed rate and the doctors billed rate, in all probability, the insurer actually makes money on most claims, not just on the policies.
The whole system is fraudulent. From end to end. And it actually got worse because of obamacare because the price on zero copay accounts skyrocketed. Which is part of how you know the copay figures are complete bullshit. The differential between the copay and the non-copay accounts are astronomical. They didn't used to be. Obamacare didn't create affordable accounts, it made all the accounts unafordable, because the ones on the lower end, aren't really insurance.