GDRR Working Group V: Healthcare Risk Assessment (e.g., frauds)

Group Leaders:
Tahir Ekin (Texas State University)


Health care expenditures constitute a significant portion of governmental budgets. The percentage of fraud, waste and abuse within that spending has increased over years. Fraud has been around since the early days of commerce, continuously evolving and adapting to changing times. The current fraud instances can be seen in a wide range of domains such as money laundering, e-commerce and insurance. Among these, medical fraud has recently attracted more attention because of the increases in healthcare spending and overpayments especially in the developed countries. A variety of statistical methods are utilized in order to detect the suspicious activities prior to the audits. Then, medical auditors investigate both intentional and unintentional wrongdoings to reveal the overpayments. The use of statistical methods such as sampling and data mining has been extensively explored in the domain of medical fraud assessment. However, the complex nature of claims data and heterogeneity of medical systems would still benefit from new methods. The integration of statistical methods within decision making frameworks is one such area.

Questions: email

Program on Games, Decisions, Risk and Reliability (GDRR)