AN EFFECTIVE HEALTH CARE INSURANCE FRAUD AND ABUSE DETECTION SYSTEM

Abstract

Due to the complexity of the processes within healthcare insurance systems and the large number of participants involved, it is very difficult to supervise the systems for fraud. The healthcare service providers’ fraud and abuse has become a serious problem. The practices such as billing for services that were never rendered, performing unnecessary medical services and misrepresenting non-covered treatment as covered treatments etc. not only contribute to the problem of rising health care expenditure but also affect the health of the patients. Traditional methods of detecting health care fraud and abuse are time-consuming and inefficient. In this paper, the health care insurance fraud and abuse detection system (HECIFADES) was proposed. The HECIFADES consist of six modules namely: claim, augment claim, claim database, profile database, profile updater and updated profiles. The system was implemented using Visual Studio 2010 and SQL. After testing, it was observed that HECIFADES was indeed an effective system for detecting fraudulent activities and yet very secured way for generating medical claims. It also improves the quality and mitigates potential payment risks and program vulnerabilities.