Supervised learning technique is data mining task of deducing a function from a labelled training data. In the context of health insurance fraud detection the class labels may termed as “legitimate” and “fraudulent” claims. The training dataset can be used to build the model.
Can data mining detect health care fraud and abuse?
ing the use of data mining applications in healthcare is the realization that data mining can generate information that is very useful to all parties involved in the healthcare industry. For example, data mining applications can help healthcare insurers detect fraud and abuse, and healthcare providers can
What is data mining and why is it important for insurance?
Data mining can help third-party payers such as health insurance organizations to extract useful information from thousands of claims and identify a smaller subset of the claims or claimants for further assessment. We reviewed studies that performed data mining techniques for detecting health care fraud and abuse, using supervised and unsupervised data mining approaches.
When is an impermissible use or disclosure a breach of HIPAA?
this instance a medical insurance provider – used data mining to build models based on previously audited claims to identify potentially fraudulent claims. With these models in place, the provider’s claim audit selection will be more exact, generate more money through claim adjustments and save time and manpower.
How do RAC contractors use data mining to deny payments?
In which type of health information exchange architectural model Does the entity operate much like an Application Service Provider ASP or bank vault?
In which type of health information exchange architectural model does the entity operate much like an application service provider (ASP) or bank vault? The federated architectural type has become more prevalent for health information organizations. There are two forms of this architecture.
Which of the following is an example of primary purpose of the health record?
The health record is known by different names in different healthcare settings. However, no matter what term is used, the primary function of the health record is to document and support patient care services.
What is the first step in a hypothesis testing procedure quizlet?
Terms in this set (39)State hypothesis about the population.Use hypothesis to predict the characteristics the sample should have.Obtain a sample from the population.Compare data with the hypothesis prediction.
Which are examples of secondary use of health information?
secondary use of data—non-direct care use of PHI including but not limited to analysis, research, quality/safety measurement, public health, payment, provider certification or accreditation, and marketing and other business including strictly commercial activities.Oct 9, 2006
Which term was used starting in the late 1990s to describe systems that were based on imaging and the merging of data from various stand alone systems?
False - The term electronic medical record (EMR) was used in the late 1990s to describe systems that were based on imaging and the merging of data from various stand-alone systems. Computerized medical record systems were first used in the 1970s.
What is the purpose of a hypothesis test quizlet?
What is the goal of hypothesis testing? To try to show that the null hypothesis is false, that the treatment does have an effect. The chance/probability that one is willing to risk in concluding that the hypothesis is correct or mistaken.
What are the 5 steps in hypothesis testing?
There are 5 main steps in hypothesis testing:State your research hypothesis as a null hypothesis (Ho) and alternate hypothesis (Ha or H1).Collect data in a way designed to test the hypothesis.Perform an appropriate statistical test.Decide whether to reject or fail to reject your null hypothesis.More items...•Nov 8, 2019
What are the steps of hypothesis testing quizlet?
Terms in this set (10)Determine the Hypotheses.Determine critical value based on a. ... Explicitly state the decision rule. ... Calculate the test statistic. ... State the decision relative to the null hypothesis (based on critical value approach)State the decision relative to the alternative hypothesis.More items...
What is Medicare for the elderly?
Medicare is a U.S. government program that provides healthcare insurance and financial support for the elderly population, ages 65 and older, and other select groups of beneficiaries [ 5 ]. Within the Medicare program, each covered medical procedure is codified for claims and payment purposes.
What is a false positive error rate?
Type I error rate (false positive rate) is the percentage of instances that are actually non-fraud but marked as fraud, in relation to the number of actual non-fraud instances. A fire alarm going off indicating a fire when in fact there is no fire would be an example of this kind of error. Type II error rate (false negative rate) is the percentage of instances that are actually fraud but marked as non-fraud, in relation to the actual number of actual fraud instances. As an example, a fire breaking out and the fire alarm does not ring would be considered a false negative. Note that in binary classification, finding a balance between the error rates, while minimizing the Type II error rate, is generally preferred. Recall measures the ability of a classifier to determine the rate of positively marked instances that are in fact positive; therefore, in our study, recall is the fraction of physicians labeled correctly and not as any of the other specialties. Precision indicates how well a classifier has predicted a class by finding the ratio of actually positive instances from the pool of instances that it has marked as part of the positive class; therefore, precision shows the fraction of physicians marked correctly against the number of physicians, from any of the other specialties, also marked as the class in question.
Does Medicare Part B include fraud labels?
In order to validate fraud detection performance, we need labels indicating fraudulent provider claims. The Medicare Part B dataset does not include fraud labels; thus, we incorporate the List of Excluded Individuals and Entities (LEIE) database [ 20 ], which includes physicians who have been found to be in violation of one or more rules within Sections 1128 and 1156 of the Social Security Act [ 29 ]. The LEIE contains all current physicians who have been found unsuited to practice medicine and thus excluded from practicing in the United States for a given period of time. The Office of the Inspector General (OIG) is responsible for maintaining the LEIE, where the individuals on the exclusion list, under Section 1128, have convictions for crimes related to a healthcare program or patient abuse and neglect. This includes being convicted of a felony for fraud or the misuse of controlled substances, and are considered mandatory exclusions. After reviewing the violations under the aforementioned sections, we decided to only incorporate physicians with mandatory exclusions (Section 1128). Even though the LEIE database provides known provider-level exclusions, it is not a complete record of all known provider fraud, where 38% with fraud convictions continue to practice medicine and 21% were not suspended from medical practice despite their convictions [ 30 ]. This lack of knowledge regarding all possible fraudulent providers could lead to predicting a provider as fraudulent when they are not, or vice versa, which may reduce the overall accuracy of a prediction model. Even so, fraud cases, like most criminal cases, are only known because those individuals were caught by law enforcement. There are many cases for which the perpetrators are never caught, thus we have no record of these activities. The exact size of annual theft is unknown and is the subject of debate, for which healthcare fraud likely costs tens of billions of dollars a year#N#Footnote#N#2.
Is Medicare fraud a problem?
Medicare fraud continues to be a problem for the U.S. government and its beneficiaries. Reducing the impact of fraud is critical in helping to reduce costs and provide high quality of service. In our study, we demonstrate, through the use of data mining and machine learning, the successful detection of Part B provider fraud for different medical specialties. In our previous research, we created a unique model to detect fraud by predicting a physician’s specialty. If this predicted (or expected) specialty differs from that physician’s actual specialty, as listed in the Medicare Part B data, this could be indicative of possible fraud. The reason is that this misclassified physician is not performing procedures in a manner similar to their peers, which is considered to be anomalous. For instance, a physician who’s expected specialty differs from their actual specialty could be performing fraudulent acts such as double billing, upcoding [ 21 ], or otherwise purposefully coding incorrect procedures. There are many examples of these types of fraudulent behaviors, and the interested reader can find a sample real-world Medicare conviction for upcoding at [ 39 ].
What is the Medical Record Committee?
The Medical Record Committee is assessing various strategies to improve documentation in the health record. Concerns have been raised that current documentation practices may be insufficient to support diagnoses or reflect the progress and clinical findings in patient care.
What does Carolyn do in Medicare?
a) Review claims for errors prior to releasing information to the Medicare program. Carolyn works as a coder in a hospital inpatient department. She sees a lab report in a patient's health record that is positive for staph infection; however, there is no mention of staph in the physician's documentation.
What is a quantitative review of the health record for missing reports and signatures that occurs when the patient is in the
A quantitative review of the health record for missing reports and signatures that occurs when the patient is in the hospital is referred to as a. Clinical privileges. When a physician is appointed to the medical staff of a healthcare organization, their scope of practice is determined by.
What is the term for the type of data that is free text and has no specific requirements or rules for data entry?
Safeguards established to support the data being available when and where is it needed under the data quality model is called: unstructured data. This type of data entered into electronic systems is free text and has no specific requirements or rules for data entry. Data ownership.
What is a health record technician?
A health record technician is preparing a bill for a patient who has two different third-party payers. Verification of the payers has been performed. Before either of the payers can be billed, the health record technician has to: A patient belonged to a managed care plan and had an elective surgery.