1st Edition

Statistics and Health Care Fraud How to Save Billions

By Tahir Ekin Copyright 2019
    160 Pages
    by Chapman & Hall

    160 Pages
    by Chapman & Hall

    Statistics and Health Care Fraud: How to Save Billions helps the public to become more informed citizens through discussions of real world health care examples and fraud assessment applications. The author presents statistical and analytical methods used in health care fraud audits without requiring any mathematical background. The public suffers from health care overpayments either directly as patients or indirectly as taxpayers, and fraud analytics provides ways to handle the large size and complexity of these claims.

    The book starts with a brief overview of global healthcare systems such as U.S. Medicare. This is followed by a discussion of medical overpayments and assessment initiatives using a variety of real world examples. The book covers subjects as:

    • Description and visualization of medical claims data

    • Prediction of fraudulent transactions

    • Detection of excessive billings

    • Revealing new fraud patterns

    • Challenges and opportunities with health care fraud analytics

    Dr. Tahir Ekin is the Brandon Dee Roberts Associate Professor of Quantitative Methods in McCoy College of Business, Texas State University. His previous work experience includes a working as a statistician on health care fraud detection. His scholarly work on health care fraud has been published in a variety of academic journals including International Statistical Review, The American Statistician, and Applied Stochastic Models in Business and Industry. He is a recipient of the Texas State University 2018 Presidential Distinction Award in Scholar Activities and the ASA/NISS y-Bis 2016 Best Paper Awards. He has developed and taught courses in the areas of business statistics, optimization, data mining and analytics. Dr. Ekin also serves as Vice President of the International Society for Business and Industrial Statistics.

    1 Health Care Systems and Fraud

    Overview

    Health care systems

    Worldwide health care insurance programs

    Medical overpayments

    Why health care fraud? Why now?

    Impact and importance of fraud assessment

    Types and examples of health care fraud

    General fraud assessment framework and initiatives

    Key takeaways

    Additional resources

    2 Describing Health Care Claims Data

    Overview

    Health care data

    Understanding health care claims data

    Data pre-processing

    Descriptive statistical analysis

    Discussion

    Key takeaways

    Additional resources

    3 Sampling and Overpayment Estimation

    Overview

    Sampling and overpayment estimation

    Sampling procedures

    A closer look at stratified sampling

    Overpayment estimation

    Discussion

    Key takeaways

    Additional resources

    4 Predicting Health Care Fraud

    Overview

    Health care fraud analytics

    Predictive methods

    Prediction of overpayment amount and fraud probability

    Classification of health care claims

    Accuracy and validation

    Discussion

    Key takeaways

    Additional resources

     

    5 Discovery of New Fraud Patterns

    Overview

    Outlier detection: Finding excessive billings

    Clustering: Grouping health care claims

    Association: Finding links among claims

    Effectiveness of the analytical methods

    Deployment via rules

    Current efforts

    Key takeaways

    Additional resources

    6 Challenges, Opportunities and Future Directions

    Overview

    Shareholders: putting a face on fraudsters and victims

    Challenges with payment and fraud control systems

    Organizational issues: "No news is good news!"

    Evolution of fraud and adaptive fraudsters

    Different sides of the coin: Data as a blessing, data as a curse

    Legal concerns: Embracing uncertainty

    A take on future

    Key takeaways

    Additional resources

    Bibliography

    Index

    Biography

    Dr. Tahir Ekin is the Brandon Dee Roberts Associate Professor of Quantitative Methods in McCoy College of Business, Texas State University. His previous work experience includes a working as a statistician on health care fraud detection. His scholarly work on health care fraud has been published in a variety of academic journals including International Statistical Review, The American Statistician, and Applied Stochastic Models in Business and Industry. He is a recipient of the Texas State University 2018 Presidential Distinction Award in Scholar Activities and the ASA/NISS y-Bis 2016 Best Paper Awards. He has developed and taught courses in the areas of business statistics, optimization, data mining and analytics. Dr. Ekin also serves as Vice President of the International Society for Business and Industrial Statistics.

    " . . . the book is well organized and clearly written on a cutting-edge topic. This book may be helpful to the applied statisticians, health care policymakers, insurance analyst, forensic accountant as well as tax office to prevent health care fraud."
    Kuldeep Kumar, Bond University, Robina, QLD, Australia