Abstract
Fraud in healthcare is widespread, as doctors could prescribe unnecessary treatments to increase bills. Insurance companies want to detect these anomalous fraudulent bills and reduce their losses. Traditional fraud detection methods use expert rules and manual data processing. Recently, machine learning techniques automate this process, but hand-labeled data is extremely costly and usually out of date. We propose a machine learning model that automates fraud detection in an unsupervised way. Two deep learning approaches include LSTM neural network for prediction next patient visit and a seq2seq model. For normalization of produced anomaly scores, we propose Empirical Distribution Function (EDF) approach. So, the algorithm works with high class imbalance problems.
We use real data on sequences of patients’ visits data from Allianz company for the validation. The models provide state-of-the-art results for unsupervised anomaly detection for fraud detection in healthcare. Our EDF approach further improves the quality of LSTM model.
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Acknowledgments
We thank Martin Spindler for providing the data and Ivan Fursov for providing code for data processing. This work was supported by the federal program “Research and development in priority areas for the development of the scientific and technological complex of Russia for 2014–2020” via grant RFMEFI60619X0008.
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Snorovikhina, V., Zaytsev, A. (2021). Unsupervised Anomaly Detection for Discrete Sequence Healthcare Data. In: van der Aalst, W.M.P., et al. Analysis of Images, Social Networks and Texts. AIST 2020. Lecture Notes in Computer Science(), vol 12602. Springer, Cham. https://doi.org/10.1007/978-3-030-72610-2_30
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