Outlier detection in healthcare fraud: A case study in the Medicaid dental domain

Health care insurance fraud is a pressing problem, causing substantial and increasing costs in medical insurance programs. Due to large amounts of claims submitted, estimated at 5 billion per day, review of individual claims or providers is a difficult task. This encourages the employment of automated pre-payment controls and better post-payment decision support tools to enable subject matter expert analysis. This paper presents how to apply unsupervised outlier techniques at post-payment stage to detect fraudulent patterns of received insurance claims. A special emphasis in this paper is put on the system architecture, the metrics designed for outlier detection and the flagging of suspicious providers which may support the fraud experts in evaluating providers and reveal fraud. The algorithms were tested on Medicaid data encompassing 650,000 health-care claims and 369 dentists of one state. Two health care fraud experts evaluated flagged cases and concluded that 12 of the top 17 providers (71%) submitted suspicious claim patterns and should be referred to officials for further investigation. The remaining 5 providers (29%) could be considered mis-classifications as their patterns could be explained by special characteristics of the provider. Selecting top flagged providers is demonstrated to be a valuable as an targeting method, and individual provider analysis revealed some cases of potential fraud. The study concludes that, through outlier detection, new patterns of potential fraud can be identified and possibly utilized in future automated detection mechanisms.     

Employer strategies to combat health care plan fraud

Each year health care fraud drains millions of dollars from employer-sponsored health plans. Historically, employers have taken a rather tolerant view of fraud. As the pressure to manage health plan costs increases, however, many employers are beginning to see the detection and prosecution of fraud as an appropriate part of a cost management program. Fraud in medical insurance covers a wide range of activities in terms of cost and sophistication--from misrepresenting information on a claim, to billing for services never rendered, to falsifying the existence of an entire medical organization. To complicate matters, fraudulent activities can emanate from many, many sources. Perpetrators can include employees, dependents or associates of employees, providers and employees of providers--virtually anyone able to make a claim against a plan. This article addresses actions that employers can take to reduce losses from fraud. The first section suggests policy statements and administrative procedures and guidelines that can be used to discourage employee fraud. Section two addresses the most prevalent form of fraud--provider fraud. To combat provider fraud, employers should set corporate guidelines and should enlist the assistance of employees in identifying fraudulent provider activities. Section three suggests ways to improve fraud detection through the claims payment system--often the first line of defense against fraud. Finally, section four discusses the possibility of civil and criminal remedies and reviews the legal theories under which an increasing number of fraud cases have been prosecuted.     

Providers’ affiliation,insurance and collusion

This paper provides a theoretical analysis of the benefits for an insurance company to develop its own network of service providers when insurance fraud is characterized by collusion between policyholders and providers. In a static framework without collusion, exclusive affiliation of providers allows insurance companies to recover some market power and to lessen competition on the insurance market. This entails a decrease in the insured’s welfare. However, exclusive affiliation of providers may entail a positive effect on customers’ surplus when insurers and providers are engaged in a repeated relationship. In particular, while insurers must cooperate to retaliate against a fraudulent provider under non-exclusive affiliation, no cooperation is needed under exclusive affiliation. In that case, an insurer is indeed able to reduce the profit of a malevolent provider by moving to collusion-proof contracts when collusion is detected, and this threat may act as a deterrent for fraudulent activities. This possibility may supplement an inefficient judicial system: it is thus a second-best optimal anti-fraud policy.     

Holliston Helping Hands

This case focuses on fraud investigation in a not‐for‐profit organization, along with an examination of governance and management control practices. The student assumes the role of an accountant investigating a possible fraud. The student is first presented with sample invoices paid by the organization that are fraught with irregularities and red flags of potential fraud. Drawing on the student's knowledge of control systems and corporate governance, the student's task is to identify suspicions of possible fraudulent transactions, identify key suspects, and develop an investigative plan. The class can also discuss recommendations to improve governance and control mechanisms to avoid future occurrences of fraud. The case is presented in three parts, and closely parallels a fraud investigation as additional information is revealed in each successive part of the case. This is much like peeling the layers of an onion which is a common way to describe the evolution of a fraud investigation. This case is based on a real fraud investigation conducted by one of the authors who was engaged by the province's Ministry of Health. Students who express disbelief about issues portrayed in the case can be reassured that these faithfully represent actual events.     

Insurance Fraud

Insurance fraud is a major problem in the United States at the beginning of the 21st century. It has no doubt existed wherever insurance policies are written, taking different forms to suit the economic time and coverage available. From the advent of “railway spine” in the 19th century to “trip and falls” and “whiplash” in the 20th century, individuals and groups have always been willing and able to file bogus claims. The term fraud carries the connotation that the activity is illegal with prosecution and sanctions as the threatened outcomes. The reality of current discourse is a much more expanded notion of fraud that covers many unnecessary, unwanted, and opportunistic manipulations of the system that fall short of criminal behavior. Those may be better suited to civil adjudicators or legislative reformers. This survey describes the range of these moral hazards arising from asymmetric information, especially in claiming behavior, and the steps taken to model the process and enhance detection and deterrence of fraud in its widest sense. The fundamental problem for insurers coping with both fraud and systemic abuse is to devise a mechanism that efficiently sorts claims into categories that require the acquisition of additional information at a cost. The five articles published in this issue of the Journal of Risk and Insurance advance our knowledge on several fronts. Measurement, detection, and deterrence of fraud are advanced through statistical models, intelligent technologies are applied to informative databases to provide for efficient claim sorts, and strategic analysis is applied to property‐liability and health insurance situations.     

Jack's Sports Bar

This two‐part case focuses on indicators or red flags of a possible fraud being committed by a majority shareholder against a minority shareholder. The student assumes the role of an accountant investigating the possible fraud. In Part 1 the student is provided with a whistleblower complaint and examines the draft financial statements that will be used for the purchase price of the sale of shares by the minority shareholder to the majority shareholder. In Part 2 the student is provided with further information on inventory controls and the accounting practices. Drawing on the student's knowledge of control systems and financial statement analysis, the student's task is to identify the possible fraudulent transactions and quantify their effect.     

Cue usage in financial statement fraud risk assessments: effects of technical knowledge and decision aid use

This paper investigates the effects of technical knowledge and decision aid use on financial statement fraud risk assessments made by directors and students. More extreme fraud risk assessments are made when participants identify and process larger (smaller) numbers of diagnostic (non‐diagnostic) factors, with technical knowledge driving diagnostic factor identification. Significant decision aid‐technical knowledge effects are also found; decision aid use has a detrimental effect on high‐knowledge directors while improving performance in inexperienced, low‐knowledge students. These results suggest that although decision aids can afford gains in performance in inexperienced users, they can have unintended and/or paradoxical behavioural effects on experienced users.     

A Multi-Line Insurance Fraud Recognition System: A Government-Led Approach in Korea

This article introduces a government-led insurance fraud detection program in Korea. The Insurance Fraud Recognition System (IFRS) uses policy and claims data from multi-lines of insurance (life, automobile, and fire), employs a three-stage statistical and link analysis to identify presumably fraudulent claims by claimant or by group, and generates system reports that the government regulator draws on to make decisions. The authors evaluate the system based on the fraud statistics and IFRS results for 2004, and offer recommendations for system improvement. This article examines existing studies about fraud, industry experiments using advanced technology, and government assistance to the insurance industry's fight against fraud in selected countries. It also provides a brief overview of the Korean insurance market, especially after the recent Asian economic crisis.     

Variation in sustainability assurance practice: An analysis of accounting versus non-accounting providers

This study explores sustainability assurance (SA) practice as an arena of jurisdictional competition between accounting and non-accounting assurance providers. Prior literature on SA, a non-financial assurance practice, has documented the presence of both accounting and non-accounting firms as two major provider categories, pointing to the possibility of significant variation in practice among them. Unlike most prior studies that rely on the analysis of the content of SA reports, this article draws on an in-depth interview-based investigation of the practice. In particular, by reference to Abbott's theory of professions (1988), we explore efforts by different SA providers to claim their professional practice space. Our findings reveal notable differences in the providers' approaches to SA, both between and within the two key provider groups. We make sense of these differences as a consequence of the inter- and intra-professional competitive dynamics where different categories of providers appeal to and emphasize divergent knowledge bases and distinctive types of expertise as a way to differentiate themselves from competition and legitimize their practice approaches. This study contributes to the extant SA literature by providing a holistic overview of the practice field and an empirically drawn perspective on the nature of practice variation.     

The Dempster‐Shafer Theory: An Introduction and Fraud Risk Assessment Illustration

This article introduces the Dempster‐Shafer theory (DS theory) of belief functions for managing uncertainties, specifically in the auditing and information systems domains. The use of DS theory is illustrated by deriving a fraud risk assessment formula for a simplified version of a model developed by Srivastava et al. (2007). In this formulation, fraud risk is the normalised product of four risks: risk that management has incentives to commit fraud; risk that management has opportunities to commit fraud; risk that management has an attitude to rationalise committing fraud; and risk that an auditor's special procedures will fail to detect fraud. The article demonstrates how to use such a model to plan for a financial audit where management fraud risk is assessed to be high. In addition, it discusses whether audit planning is better served by an integrated audit/fraud risk assessment as now suggested in SAS 107 (AICPA 2006a, see also ASA 200 in AUASB 2007) or by the approach illustrated here where a parallel, but separate, assessment is made of audit risk and fraud risk.     

基于PSD-LDA模型的新农合欺诈风险测度实证研究

针对新农合欺诈风险具有"低频高损"和"高频低损"的特征,运用两阶段损失分布法(PSDLDA)测度新农合欺诈风险损失TailVaR值,以2004~2012年媒体公开报道的新农合欺诈损失数据为样本进行实证研究,计算了欺诈风险损失纯保费,并探讨了在新农合欺诈风险定价、风险准备金计提、风险补偿机制的建立以及欺诈风险预警等方面的应用。     

Why computer-mediated communication improves the effectiveness of fraud brainstorming

Current auditing standards require auditors to conduct a fraud brainstorming session aimed at considering ways in which the audit client's financial statements might be fraudulently misstated. Lynch et al. (2009) document that computer-mediated fraud brainstorming is significantly more effective than face-to-face brainstorming for generating relevant fraud risks. In this study, we code and analyze process-level data from the Lynch et al. (2009) study to understand the factors contributing to the greater effectiveness of electronic fraud brainstorming. Specifically, we conduct mediation analysis to discern the degree to which equality of participation and two measures of task focus contribute to greater fraud brainstorming effectiveness when using a computer-mediated communication system compared to traditional face-to-face brainstorming. We also examine participants' perceptions of ease of system use, satisfaction with the process, and satisfaction with the outcome. Overall, the results indicate that the primary reason for the greater effectiveness of electronic fraud brainstorming is the greater degree of task focus as revealed through the length of comments made when using computer-mediated fraud brainstorming. In an absolute sense, participants using electronic brainstorming felt that their brainstorming mode was easy to use and they were satisfied with the process and outcome. The primary contribution of this study is in enhancing our understanding of precisely why computer-mediated fraud brainstorming outperforms face-to-face fraud brainstorming.     

Building An Intelligent Business Process Reengineering System: A Case-Based Approach

The Intelligent Business Process Reengineering System (IBPRS) is an interactive expert system. This paper presents a framework for IBPRS which utilizes case-based planning and problem-solving techniques in identifying requirements and problems and in searching for alternative opportunities from previous experiences (cases). IBPRS comprises two major components: Planner and Constructor. The IBPRS Planner's problem solving consists of four stages: problem formulation, case retrieval, case refinement, and evaluation. In generating business process reengineering (BPR) alternatives, IBPRS identifies appropriate case(s) among previous BPR cases that are represented in the form of process model(s) using search algorithms and other rules stored in the Planner's knowledge base. In evaluating the generated BPR alternatives, various simulation models and economic analyses are used. The best BPR alternative is then selected through a multi-attribute criteria decision analysis. In the refinement stage, IBPRS employs case-based substitution method for case adaptation and refinement. The Planner Knowledge Base and the Case Repository are updated as new knowledge develops and new cases are built and entered into the system. The main benefits of IBPRS is to facilitate BPR efforts by identifying problems, evaluating alternatives, and choosing the most appropriate BPR alternative.     

Team discourse explains media richness and anonymity effects in audit fraud cue brainstorming

This article contributes by extending media richness (MRT) and media synchronicity theories (MST) to explore how media richness and anonymity influence team interactions and success in audit fraud brainstorming. Sixty-three, three-person teams, with 189 student participants from two Universities, identified fraud risk cues in a SAS 99 audit planning case. Participants were assigned to one of three conditions: electronic anonymity (EA; n = 18 teams), electronic identified (EI; n = 28 teams), or identified face-to-face (FtF; n = 17 teams). Compared with teams in the low media richness conditions, i.e., the EA and EI, discussions in FtF teams produced more and better dialog, which resulted in better identification of fraud risk cues. Additionally, compared with the discussions in the EA teams, FtF team discussions evidenced less narcissism and were more focused and inhibited. Mediation analyses of team interactions indicated that the quantity of dialog (team production) completely explains, fully mediates, the effects of media richness and anonymity on risk assessments. Contributions include extending MRT and MST, and using automated content analysis, to explicate the role of media richness, anonymity, and team interactions in explaining audit team fraud identification success. The concluding section identifies the sample, design, and method limitations, and, discusses the potential for group support technologies to enhance or detract from audit team processes, depending on task, context, and technology.     

Erklärungsansätze für vertragswidriges Verhalten Versicherungsnehmern aus Sicht der ökonomischen Theorie

The two main purposes of this paper are an introduction to the economic analysis of insurance fraud and furthermore a derivation of factors that determine fraudulent behavior of policyholders on insurance markets. Consequently, we analyze the strategic decision problems of insurance companies and the policyholders and identify some factors that can help to reduce fraudulent behavior. In this context we evaluate two derived starting points for the combat against insurance fraud: fraud detection systems and a consequent charge policy of detected defrauders. We illustrate that both points can help to reduce the cost of fraud. Furthermore, we enhance our earlier analysis with respect to the empirical fact that some individuals care about fairness or — in the insurance fraud context — the legitimacy of their actions. Surprisingly, in some market situations these concerns of some policyholders do not lead to a lower fraud probability. Finally, we discuss how and to what extent insurance companies can influence such ethical concerns of policyholders. On that score, we distinguish insurance specific and insurance unspecific factors and their impact on the consumers attitudes towards insurance fraud.     

The role of auditing in the fight against corruption

The purpose of this paper is to analyze how various types of auditing may contribute to fight corruption. While previous literature has primarily addressed auditing's ability to prevent corruption, this paper systematically explores auditing's potential to detect corruption. It argues that financial auditing has excluded corruption from the definition of fraud and instead classified it as ‘non-compliance with laws and regulations’. The main arguments for this exclusion is that corruption leaves no material errors in financial statements and no evidence for the auditor to follow. The paper refutes this, arguing that commercial and political corruption creates misstatements in the financial statements of the corruption giver's organization as well as the corruption receiver's organization. Thus, if auditing is to gain a more prominent role in the fight against corruption, auditing standards must include corruption in the definition of fraud, private and public sector auditors need to cooperate and exchange information, auditing techniques to detect corruption should be employed, and the auditing profession must embrace effective preventive measures such as anti-corruption certifications.     

Do female CEOs matter for ESG scores?

Environmental, social, and governance (ESG) issues are important for consumers, investors, and other stakeholders. The same applies for gender diversity. We show that whether female CEOs seem to matter for the firm's ESG profile depends crucially on the data used for the analysis: depending on the specific data provider, ESG scores for the same firms are either strongly and significantly positively associated, or not associated at all, with having a female CEO. Conclusions on this important topic are vulnerable to data discrepancies across ESG data providers.     

平台型媒体中的商业舞弊治理研究 ——基于生命周期视角

基于企业社会责任理论与企业生命周期理论,考量平台型媒体中的商业舞弊及其治理.结果发现:由于平台型媒体在各生命周期阶段的目标差异性,商业舞弊类型在平台型媒体中呈现周期性规律;随着平台发展,用户感知的平台合法性对商业舞弊有显著治理效果,即合法性为平台带来治理资源,从而提升其舞弊治理能力;不同维度合法性的治理作用与平台生命周期相关,即认知合法性的作用贯穿始终,规制合法性在引爆期的治理作用更大;平台用户的身份认知会调节平台合法性对舞弊的治理,即当用户在平台中的主导身份为供方时,合法性的治理效果会增强.     

基于BP神经网络的保险欺诈识别研究——以中国机动车保险索赔为例

当前保险欺诈在国内外呈现蔓延态势,尤其体现在机动车保险领域,欺诈识别已成为保险欺诈研究的核心内容.目前保险欺诈识别有统计回归和神经网络两大类方法,这两种方法在指导思想和识别流程上各有优缺.本文基于我国财产保险公司车险索赔样本数据,检验BP神经网络在我国保险欺诈识别中的有效性;同时为了尝试统计回归和神经网络的有效融合,本...     

Fraud at a public authority

This case describes a fraud committed at a public authority which operated a municipal facility that was used for sporting events and concerts. The fraud was committed by the authority’s chief accounting officer who stole tens of thousands of dollars in cash over a period of several years. The case describes how the cash was stolen and concealed by the authority’s chief accountant. Case questions ask students to identify internal control weaknesses that allowed the fraud to be committed, recommend improvements to internal controls, and identify how the auditor should have searched for the fraud. Assessment evidence indicates that the case is effective in meeting identified learning objectives. The case has been used in the first auditing course, and it would also be suitable for use in a forensic accounting course.