FRAUD DETECTION IN HEALTHCARE

摘要

A system for, among other purposes, detecting health care fraud, comprises a data import component for importing health care data from data source(s) such health care providers, insurers, or pharmacies; data repositor(ies) in which the data import component creates health care objects such as provider objects that describe health care providers, patient objects that represent health care recipients, and health care event objects that describe one or more of: health care claims, prescriptions, medical procedures, or diagnoses; a correlation component that identifies correlations between the health care objects; a graph generator component that generates graphs of networks identified based at least on the correlations identified by the correlation component, the graphs comprising linked nodes that represent health care objects in the identified networks; and an interface generator that generates interfaces that display the graphs generated by the graph generator.

主权项

1. A method comprising:
generating provider objects that describe health care providers; generating patient objects that describe health care recipients; generating health care event objects, the health care event objects including at least objects of a prescription event type, objects of a medical claim event type, and objects of a diagnosis event type; generating fraud objects representing known instances of health care fraud; storing the provider objects, patient objects, health care event objects, and fraud objects in a digital computer-readable storage medium; correlating the health care event objects to the provider objects and the patient objects; receiving input specifying a particular object, wherein the particular object is one of a particular provider object or a particular patient object; based on the correlating, identifying a network comprising one or more provider objects and one or more patient objects that are associated with the particular object; generating a graph of the network, the graph comprising linked nodes, the linked nodes including one or more patient nodes that represent the one or more patient objects and one or more provider nodes that represent the one or more provider objects; linking a particular provider node or a particular patient node to a fraud node within the graph, the fraud node representing a particular fraud object; wherein the method is performed by one or more computing devices.