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An evaluation of Unsupervised Machine Learning Algorithms for Detecting Fraud and Abuse in the U.S. Medicare Insurance Program

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Date Issued:
2018
Abstract/Description:
The population of people ages 65 and older has increased since the 1960s and current estimates indicate it will double by 2060. Medicare is a federal health insurance program for people 65 or older in the United States. Medicare claims fraud and abuse is an ongoing issue that wastes a large amount of money every year resulting in higher health care costs and taxes for everyone. In this study, an empirical evaluation of several unsupervised machine learning approaches is performed which indicates reasonable fraud detection results. We employ two unsupervised machine learning algorithms, Isolation Forest and Unsupervised Random Forest, which have not been previously used for the detection of fraud and abuse on Medicare data. Additionally, we implement three other machine learning methods previously applied on Medicare data which include: Local Outlier Factor, Autoencoder, and k-Nearest Neighbor. For our dataset, we combine the 2012 to 2015 Medicare provider utilization and payment data and add fraud labels from the List of Excluded Individuals/Entities (LEIE) database. Results show that Local Outlier Factor is the best model to use for Medicare fraud detection.
Title: An evaluation of Unsupervised Machine Learning Algorithms for Detecting Fraud and Abuse in the U.S. Medicare Insurance Program.
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Name(s): Da Rosa, Raquel C., author
Khoshgoftaar, Taghi M., Thesis advisor
Florida Atlantic University, Degree grantor
College of Engineering and Computer Science
Department of Computer and Electrical Engineering and Computer Science
Type of Resource: text
Genre: Electronic Thesis Or Dissertation
Date Created: 2018
Date Issued: 2018
Publisher: Florida Atlantic University
Place of Publication: Boca Raton, Fla.
Physical Form: application/pdf
Extent: 64 p.
Language(s): English
Abstract/Description: The population of people ages 65 and older has increased since the 1960s and current estimates indicate it will double by 2060. Medicare is a federal health insurance program for people 65 or older in the United States. Medicare claims fraud and abuse is an ongoing issue that wastes a large amount of money every year resulting in higher health care costs and taxes for everyone. In this study, an empirical evaluation of several unsupervised machine learning approaches is performed which indicates reasonable fraud detection results. We employ two unsupervised machine learning algorithms, Isolation Forest and Unsupervised Random Forest, which have not been previously used for the detection of fraud and abuse on Medicare data. Additionally, we implement three other machine learning methods previously applied on Medicare data which include: Local Outlier Factor, Autoencoder, and k-Nearest Neighbor. For our dataset, we combine the 2012 to 2015 Medicare provider utilization and payment data and add fraud labels from the List of Excluded Individuals/Entities (LEIE) database. Results show that Local Outlier Factor is the best model to use for Medicare fraud detection.
Identifier: FA00013042 (IID)
Degree granted: Thesis (M.S.)--Florida Atlantic University, 2018.
Collection: FAU Electronic Theses and Dissertations Collection
Note(s): Includes bibliography.
Subject(s): Machine learning
Medicare fraud
Algorithms
Held by: Florida Atlantic University Libraries
Sublocation: Digital Library
Persistent Link to This Record: http://purl.flvc.org/fau/fd/FA00013042
Use and Reproduction: Copyright © is held by the author, with permission granted to Florida Atlantic University to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
Use and Reproduction: http://rightsstatements.org/vocab/InC/1.0/
Owner Institution: FAU
Is Part of Series: Florida Atlantic University Digital Library Collections.