Handbook of Artificial Intelligence

Investigating and Identifying Fraudulent Behaviors of Medical Claims Data Using Machine Learning Algorithms

Author(s): Jyothi P. Naga*, K.V.S.N. Rama Rao, L. Rajya and S. Suresh

Pp: 231-254 (24)

DOI: 10.2174/9789815124514123010015

* (Excluding Mailing and Handling)

Abstract

Healthcare is essential in pandemic times, but it is crucial for the well-being of daily life. Many countries allocate substantial funds towards providing high-quality healthcare services. As healthcare expenses escalate, policymakers and funders are increasingly focused on investigating the underlying factors driving the high costs of medical resources. A comprehensive analysis carried the required expenses towards identification, valuation, and measurement of resources utilized for the diagnosis process. The objective of the chapter is to provide how the data analysis is carried which helps to identify fraudulent behaviors. The generated model assists health management organizations in identifying suspicious behaviors toward claims. Healthcare fraud is a severe threat to global health results, and could lead to misuse, scarce resources, and negative impacts on healthcare access, infrastructures, and social determinants of health. Healthcare fraud is associated with increased healthcare costs in most of the leading countries. The proposed research work provides an estimation mechanism for utilizing health resources and their impacts on healthcare costs. This chapter proposes strategic ways of handling healthcare data to prevent future healthcare fraud, decrease healthcare expenditure, and adequately use resources to benefit the population. This chapter works on three primary datasets and a synthetic dataset aggregated from the primary datasets. The data preprocessing is carried out at different levels of the model, which truly enhances the data quality. The model is constructed at three levels; the first level analyzes datasets in which it extracts the primary features and provides constructive decisions and outcomes on the processing of data. Regressive analysis of the hierarchical grouping mechanism helps to know the detailed features that could affect healthcare and prevent resource misuse. 

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      • 16. vendor/laravel/framework/src/Illuminate/Routing/ControllerDispatcher.php:43
      • 17. vendor/laravel/framework/src/Illuminate/Routing/Route.php:260
    • (select j.user_access_id,j.volume_id,j.user_id,j.from_ip,j.to_ip,j.type,j.track,"Trial Access" as access_base_text, CASE j.type WHEN 111 THEN true ELSE false END as terms_popup, "S" as content_download_type, null as restricted_user_access_key, null as restricted_user_access_type, CASE j.track WHEN 0 THEN false ELSE true END as tracksAccessByVolume,"chapter" as access_level, j.chapter_id from `user_access_chapter_trail` as `j` inner join `user_access_info` as `info` on `j`.`user_access_id` = `info`.`user_access_id` where ((j.from_ip <= 59769557 and j.to_ip >=59769557 )) and ((j.from_date <= 1739834910 and j.to_date >= 1739834910 and j.perpetual= 0) or (j.from_date is null and j.to_date is null and j.perpetual= 1)) and j.chapter_id = 20837) union (select j.user_access_id,j.volume_id,j.user_id,j.from_ip,j.to_ip,j.type,j.track,"Subscribed" as access_base_text, false as terms_popup, "S" as content_download_type, null as restricted_user_access_key, null as restricted_user_access_type, CASE j.track WHEN 0 THEN false ELSE true END as tracksAccessByVolume,"chapter" as access_level, j.chapter_id from `user_access_chapter_corporate` as `j` inner join `user_access_info` as `info` on `j`.`user_access_id` = `info`.`user_access_id` where ((j.from_ip <= 59769557 and j.to_ip >=59769557 )) and ((j.from_date <= 1739834910 and j.to_date >= 1739834910 and j.perpetual= 0) or (j.from_date is null and j.to_date is null and j.perpetual= 1)) and j.chapter_id = 20837) union (select j.user_access_id,j.volume_id,j.user_id,j.from_ip,j.to_ip,j.type,j.track,"Token Based Access" as access_base_text, false as terms_popup, "R" as content_download_type, j.uc_id as restricted_user_access_key, "v" as restricted_user_access_type, CASE j.track WHEN 0 THEN false ELSE true END as tracksAccessByVolume,"chapter" as access_level, j.chapter_id from `user_access_chapter_token` as `j` inner join `user_access_info` as `info` on `j`.`user_access_id` = `info`.`user_access_id` where ((j.from_ip <= 59769557 and j.to_ip >=59769557 )) and ((j.from_date <= 1739834910 and j.to_date >= 1739834910 and j.perpetual= 0) or (j.from_date is null and j.to_date is null and j.perpetual= 1)) and j.chapter_id = 20837)
      750μsalphaeurekaselec_live_10_06_2022UserAccess.php#1266
      Backtrace
      • 13. app/Models/UserAccess/UserAccess.php:1266
      • 14. app/Http/Controllers/ChapterController.php:1549
      • 15. vendor/laravel/framework/src/Illuminate/Routing/Controller.php:54
      • 16. vendor/laravel/framework/src/Illuminate/Routing/ControllerDispatcher.php:43
      • 17. vendor/laravel/framework/src/Illuminate/Routing/Route.php:260
    • select b.banner_link, b.banner_name, b.banner_script, b.banner_remarks, b.banner_file_name, b.banner_placement, bd.content_type, bd.content_id from `tbl_banner` as `b` inner join `tbl_banner_detail` as `bd` on `bd`.`banner_id` = `b`.`banner_id` inner join `users` as `u` on `u`.`id` = `b`.`updated_by` where `b`.`banner_ebook` = 1 and `bd`.`content_type` = 'B' and `bd`.`content_id` = 3615 and `b`.`banner_from_date` <= 1739834910 and `b`.`banner_to_date` >= 1739834910 and `b`.`banner_status` = 'A' order by `b`.`banner_id` desc
      1.09msalphaeurekaselec_live_10_06_2022Banner.php#95
      Bindings
      • 0: 1
      • 1: B
      • 2: 3615
      • 3: 1739834910
      • 4: 1739834910
      • 5: A
      Backtrace
      • 13. app/Models/Banner.php:95
      • 14. app/Http/helpers.php:404
      • 17. vendor/laravel/framework/src/Illuminate/Filesystem/Filesystem.php:124
      • 18. vendor/laravel/framework/src/Illuminate/View/Engines/PhpEngine.php:58
      • 19. vendor/laravel/framework/src/Illuminate/View/Engines/CompilerEngine.php:73
    • select count(*) as aggregate from `uc_cart_products` where cart_id='1becc78e59e7dd1d042cf5c09563f761'
      240μsalphaeurekaselec_live_10_06_2022Cart.php#271
      Backtrace
      • 15. app/Models/Cart.php:271
      • 16. view::layouts._header:260
      • 18. vendor/laravel/framework/src/Illuminate/Filesystem/Filesystem.php:124
      • 19. vendor/laravel/framework/src/Illuminate/View/Engines/PhpEngine.php:58
      • 20. vendor/laravel/framework/src/Illuminate/View/Engines/CompilerEngine.php:73
    App\Models\Chapter
    1Chapter.php#?
    App\Models\Ebook
    1Ebook.php#?
        _token
        kUpdFoBCKsgsLKmqCtIi07jXOVea4rm4oGZu17Us
        uc_cart_id
        1becc78e59e7dd1d042cf5c09563f761
        _previous
        array:1 [ "url" => "https://alpha.eurekaselect.com/chapter/20837" ]
        _flash
        array:2 [ "old" => [] "new" => [] ]
        PHPDEBUGBAR_STACK_DATA
        []
        path_info
        /chapter/20837
        status_code
        200
        
        status_text
        OK
        format
        html
        content_type
        text/html; charset=UTF-8
        request_query
        []
        
        request_request
        []
        
        request_headers
        0 of 0
        array:17 [ "x-https" => array:1 [ 0 => "1" ] "host" => array:1 [ 0 => "alpha.eurekaselect.com" ] "priority" => array:1 [ 0 => "u=0, i" ] "cookie" => array:1 [ 0 => "wayfindertarget=eyJpdiI6InVpTENJUjAwQ1RZYkU4djJXRlVwR1E9PSIsInZhbHVlIjoiQmhFSm94SnZwcDRpMHRRcVB5N0orTXUyaVMvdnlJUFpha24yMEJIV1k1WT0iLCJtYWMiOiI5YzczNTBlOTQzMzM0YTkxZmVkMzI1OWIxNjBjYTdiODcyNDI4MDE4MzViM2Q3NWMyMDRlOTE5MGFiZmVkNzQ3IiwidGFnIjoiIn0%3D; _ga_9F3B5VV3T3=GS1.1.1739834910.1.0.1739834910.60.0.0; _ga=GA1.1.403378762.1739834910wayfindertarget=eyJpdiI6InVpTENJUjAwQ1RZYkU4djJXRlVwR1E9PSIsInZhbHVlIjoiQmhFSm94SnZwcDRpMHRRcVB5N0orTXUyaVMvdnlJUFpha24yMEJIV1k1WT0iLCJtYWMiOiI5YzczNTBlOTQzMzM0" ] "accept-encoding" => array:1 [ 0 => "gzip, deflate, br, zstd" ] "sec-fetch-dest" => array:1 [ 0 => "document" ] "sec-fetch-user" => array:1 [ 0 => "?1" ] "sec-fetch-mode" => array:1 [ 0 => "navigate" ] "sec-fetch-site" => array:1 [ 0 => "none" ] "accept" => array:1 [ 0 => "text/html,application/xhtml+xml,application/xml;q=0.9,image/avif,image/webp,image/apng,*/*;q=0.8,application/signed-exchange;v=b3;q=0.7" ] "user-agent" => array:1 [ 0 => "Mozilla/5.0 AppleWebKit/537.36 (KHTML, like Gecko; compatible; ClaudeBot/1.0; +claudebot@anthropic.com)" ] "upgrade-insecure-requests" => array:1 [ 0 => "1" ] "sec-ch-ua-platform" => array:1 [ 0 => ""Windows"" ] "sec-ch-ua-mobile" => array:1 [ 0 => "?0" ] "sec-ch-ua" => array:1 [ 0 => ""HeadlessChrome";v="129", "Not=A?Brand";v="8", "Chromium";v="129"" ] "cache-control" => array:1 [ 0 => "no-cache" ] "pragma" => array:1 [ 0 => "no-cache" ] ]
        request_cookies
        0 of 0
        array:3 [ "wayfindertarget" => null "_ga_9F3B5VV3T3" => null "_ga" => null ]
        response_headers
        0 of 0
        array:5 [ "content-type" => array:1 [ 0 => "text/html; charset=UTF-8" ] "cache-control" => array:1 [ 0 => "no-cache, private" ] "date" => array:1 [ 0 => "Mon, 17 Feb 2025 23:28:30 GMT" ] "set-cookie" => array:2 [ 0 => "XSRF-TOKEN=eyJpdiI6InhnQzREaHFNTnNHTUxYTWpOK1c1SGc9PSIsInZhbHVlIjoiU1hEZ0QyazR0Z3plYldiTlpWNHdFQlpaa2czYjM5dGZESERjMittRkF0ZW4xWnEwSVNLR3d5WDd6WDBWM1JnQmZNU2ZUNWV4V2NhTmJBNVA2MFRvUFQxbDUzcm1ZZTBlSEtmWkE0S0tYRE92VWMvRjlyeEhEMmkyRWY2MWErK0IiLCJtYWMiOiJlZWFmYzI0NjZkNmFjOTllODM1MzFiYzk0MWQyYzY3MTAzNGEwODU4OTU3ZTJiMDNjNTUyMDU4NzZmMGVhMjM4IiwidGFnIjoiIn0%3D; expires=Thu, 20 Feb 2025 11:28:30 GMT; Max-Age=216000; path=/; secure; samesite=laxXSRF-TOKEN=eyJpdiI6InhnQzREaHFNTnNHTUxYTWpOK1c1SGc9PSIsInZhbHVlIjoiU1hEZ0QyazR0Z3plYldiTlpWNHdFQlpaa2czYjM5dGZESERjMittRkF0ZW4xWnEwSVNLR3d5WDd6WDBWM1JnQmZNU2ZUN" 1 => "alphaeurekaselectnet_session=eyJpdiI6IjR3eWs5a3ZzQ1RPaWhYWkhPMHVBTlE9PSIsInZhbHVlIjoiVW9ZVGx4YjllVVhVS1diSXNWY2U4UjBEN2VFRFIyZDkyZzBDQlFRUkx6Q3VqQmNQRUxLckpEOG5LaXdZdElGdjBscVU3U3hMdkFueGMvQnUrcXVBSzg5Q0RJQXRHZEliaURtMDAxclloVlh4dTJKYzkyei95REVwZEVjQURsUXAiLCJtYWMiOiIyMWJiYTU1ZDA1MzU2NTFmMjI5NDM0MmY1NWY2NDI2OTk4ZWM4OTE1ODJlNDRjYjczZjUxMWM0NzgxYjRjN2NhIiwidGFnIjoiIn0%3D; path=/; secure; httponly; samesite=laxalphaeurekaselectnet_session=eyJpdiI6IjR3eWs5a3ZzQ1RPaWhYWkhPMHVBTlE9PSIsInZhbHVlIjoiVW9ZVGx4YjllVVhVS1diSXNWY2U4UjBEN2VFRFIyZDkyZzBDQlFRUkx6Q3VqQmNQRUxLckpEOG5" ] "Set-Cookie" => array:2 [ 0 => "XSRF-TOKEN=eyJpdiI6InhnQzREaHFNTnNHTUxYTWpOK1c1SGc9PSIsInZhbHVlIjoiU1hEZ0QyazR0Z3plYldiTlpWNHdFQlpaa2czYjM5dGZESERjMittRkF0ZW4xWnEwSVNLR3d5WDd6WDBWM1JnQmZNU2ZUNWV4V2NhTmJBNVA2MFRvUFQxbDUzcm1ZZTBlSEtmWkE0S0tYRE92VWMvRjlyeEhEMmkyRWY2MWErK0IiLCJtYWMiOiJlZWFmYzI0NjZkNmFjOTllODM1MzFiYzk0MWQyYzY3MTAzNGEwODU4OTU3ZTJiMDNjNTUyMDU4NzZmMGVhMjM4IiwidGFnIjoiIn0%3D; expires=Thu, 20-Feb-2025 11:28:30 GMT; path=/; secureXSRF-TOKEN=eyJpdiI6InhnQzREaHFNTnNHTUxYTWpOK1c1SGc9PSIsInZhbHVlIjoiU1hEZ0QyazR0Z3plYldiTlpWNHdFQlpaa2czYjM5dGZESERjMittRkF0ZW4xWnEwSVNLR3d5WDd6WDBWM1JnQmZNU2ZUN" 1 => "alphaeurekaselectnet_session=eyJpdiI6IjR3eWs5a3ZzQ1RPaWhYWkhPMHVBTlE9PSIsInZhbHVlIjoiVW9ZVGx4YjllVVhVS1diSXNWY2U4UjBEN2VFRFIyZDkyZzBDQlFRUkx6Q3VqQmNQRUxLckpEOG5LaXdZdElGdjBscVU3U3hMdkFueGMvQnUrcXVBSzg5Q0RJQXRHZEliaURtMDAxclloVlh4dTJKYzkyei95REVwZEVjQURsUXAiLCJtYWMiOiIyMWJiYTU1ZDA1MzU2NTFmMjI5NDM0MmY1NWY2NDI2OTk4ZWM4OTE1ODJlNDRjYjczZjUxMWM0NzgxYjRjN2NhIiwidGFnIjoiIn0%3D; path=/; secure; httponlyalphaeurekaselectnet_session=eyJpdiI6IjR3eWs5a3ZzQ1RPaWhYWkhPMHVBTlE9PSIsInZhbHVlIjoiVW9ZVGx4YjllVVhVS1diSXNWY2U4UjBEN2VFRFIyZDkyZzBDQlFRUkx6Q3VqQmNQRUxLckpEOG5" ] ]
        session_attributes
        0 of 0
        array:5 [ "_token" => "kUpdFoBCKsgsLKmqCtIi07jXOVea4rm4oGZu17Us" "uc_cart_id" => "1becc78e59e7dd1d042cf5c09563f761" "_previous" => array:1 [ "url" => "https://alpha.eurekaselect.com/chapter/20837" ] "_flash" => array:2 [ "old" => [] "new" => [] ] "PHPDEBUGBAR_STACK_DATA" => [] ]
        ClearShow all
        Date ↕MethodURLData
        #12025-02-17 23:28:30GET/chapter/20837112192