University of Twente Student Theses


Fraud detection within Medicaid

Schoutsen, P.A.M. (2012) Fraud detection within Medicaid.

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Abstract:In 2007 a total amount of $2.26 trillion was spent on health care within the United States of America (National Health Care Anti-­‐Fraud Association, year unknown). An exact measure of fraud is unavailable. This is due to the fact that most fraud goes undetected and if it is detected it is stopped. This means there is only undetected fraud of which the size cannot be known. The National Health Care Anti-­‐Fraud Association (NHCAA) estimates that the losses due to health care fraud are in the tens of billions of dollars each year. The Federal Bureau of Investigation (2009) supports this claim by stating that three to ten percent of total billings within public and private health care are fraudulent. Besides the staggering costs of health care fraud also imposes a risk for the health of patients. One of the most significant trends observed by the Federal Bureau of Investigation (2009) is the willingness of medical professionals to risk patient harm in their fraud schemes. One of the problems that there is still so much fraud within the system is the lack of sophisticated fraud control systems. The systems are static, lack real time fraud detection and focus on fraud detection in the transaction without looking for patterns of suspicious behavior within the interactions between patients and health care providers. In these patterns might be hidden, larger, more complex and more sophisticated fraud schemes. This thesis will focus on the health insurance that the government of the United States of America provide to people with low incomes: Medicaid.
Item Type:Essay (Master)
Faculty:BMS: Behavioural, Management and Social Sciences
Subject:85 business administration, organizational science
Programme:Business Information Technology MSc (60025)
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