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

  title={A process-mining framework for the detection of healthcare fraud and abuse},
  author={Wan-Shiou Yang and San-Yih Hwang},
  journal={Expert Syst. Appl.},
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… CONTINUE READING
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