A process-mining framework for the detection of healthcare fraud and abuse

People rely on government-managed health insurance systems, private health insurance systems, or both to share the expensive healthcare costs. With such an intensive need for health insurances, however, health care service providers' fraudulent and abusive behavior has become a serious problem. In this research, we propose a data-mining framework that utilizes the concept of clinical pathways to facilitate automatic and systematic construction of an adaptable and extensible detection model. The proposed approaches have been evaluated objectively by a real-world data set gathered from the National Health Insurance (NHI) program in Taiwan. The empirical experiments show that our detection model is efficient and capable of identifying some fraudulent and abusive cases that are not detected by a manually constructed detection model. (c) 2005 Elsevier Ltd. All rights reserved.