Biomaterial Database

Using data mining to find fraud in HCFA health care claims. 2001

L Sokol, and B Garcia, and J Rodriguez, and M West, and K Johnson

Veridian Corporation, Fairfax, Virginia, USA.

Data mining can be/used to detect health care fraud and abuse through visualization of very large data sets to isolate new and unusual patterns of activity. Data mining has allowed better direction and use of health care fraud detection and investigative resources by recognizing and quantifying the underlying indicators of fraudulent claims, fraudulent providers, and fraudulent beneficiaries. A large amount of work must be performed prior to the actual data mining. These precursory tasks include: customer discussions, data extraction and cleaning, transformation of the database, and auditing (basic statistics and visualization of the information) of the data. This paper describes the tasks performed in support of a project for HCFA (Health Care Financing Administration).

UI	MeSH Term	Description	Entries
D007344	Insurance Claim Reporting	The design, completion, and filing of forms with the insurer.	Claim Reporting, Insurance,Reporting, Insurance Claim
D008327	Mammography	Radiographic examination of the breast.	3D-Mammography,Digital Breast Tomosynthesis,Digital Mammography,X-ray Breast Tomosynthesis,3D Mammography,3D-Mammographies,Breast Tomosyntheses, Digital,Breast Tomosyntheses, X-ray,Breast Tomosynthesis, Digital,Breast Tomosynthesis, X-ray,Digital Breast Tomosyntheses,Digital Mammographies,Mammographies,Mammographies, Digital,Mammography, Digital,X ray Breast Tomosynthesis,X-ray Breast Tomosyntheses
D008485	Medical Audit	A detailed review and evaluation of selected clinical records by qualified professional personnel for evaluating quality of medical care.	Audit, Medical,Audits, Medical,Medical Audits
D003625	Data Collection	Systematic gathering of data for a particular purpose from various sources, including questionnaires, interviews, observation, existing records, and electronic devices. The process is usually preliminary to statistical analysis of the data.	Data Collection Methods,Dual Data Collection,Collection Method, Data,Collection Methods, Data,Collection, Data,Collection, Dual Data,Data Collection Method,Method, Data Collection,Methods, Data Collection
D005260	Female		Females
D005607	Fraud	Exploitation through misrepresentation of the facts or concealment of the purposes of the exploiter.	Fraud, Health Care,Health Care Fraud,Kickbacks,Drug Counterfeiting,Healthcare Fraud,Counterfeiting, Drug,Fraud, Healthcare,Health Care Frauds,Kickback
D006801	Humans	Members of the species Homo sapiens.	Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D014481	United States	A country in NORTH AMERICA between CANADA and MEXICO.
D014487	Centers for Medicare and Medicaid Services, U.S.	A component of the Department of Health and Human Services to oversee and direct the Medicare and Medicaid programs and related Federal medical care quality control staffs. Name was changed effective June 14, 2001.	Centers for Medicare and Medicaid Services,United States Centers for Medicare and Medicaid Services,United States Health Care Financing Administration,Centers for Medicare and Medicaid Services (U.S.),HCFA,Health Care Financing Administration,Health Care Financing Administration (U.S.),Health Care Financing Administration, U.S.
D016208	Databases, Factual	Extensive collections, reputedly complete, of facts and data garnered from material of a specialized subject area and made available for analysis and application. The collection can be automated by various contemporary methods for retrieval. The concept should be differentiated from DATABASES, BIBLIOGRAPHIC which is restricted to collections of bibliographic references.	Databanks, Factual,Data Banks, Factual,Data Bases, Factual,Data Bank, Factual,Data Base, Factual,Databank, Factual,Database, Factual,Factual Data Bank,Factual Data Banks,Factual Data Base,Factual Data Bases,Factual Databank,Factual Databanks,Factual Database,Factual Databases