Health care fraud classifiers in practice

2021 ◽  
Author(s):  
Tahir Ekin ◽  
Luca Frigau ◽  
Claudio Conversano
Keyword(s):  
Health Care ◽  
Health Care Fraud

A survey on statistical methods for health care fraud detection

2008 ◽  
Vol 11 (3) ◽  
pp. 275-287 ◽  
Author(s):  
Jing Li ◽  
Kuei-Ying Huang ◽  
Jionghua Jin ◽  
Jianjun Shi
Keyword(s):  
Health Care ◽  
Statistical Methods ◽  
Fraud Detection ◽  
Health Care Fraud

Real-World Evidence in the Real World: Beyond the FDA

2018 ◽  
Vol 44 (2-3) ◽  
pp. 161-179 ◽  
Author(s):  
Joan H. Krause ◽  
Richard S. Saver
Keyword(s):  
Health Care ◽  
Health Care System ◽  
Real World ◽  
Regulatory Oversight ◽  
The Real ◽  
Health Care Fraud ◽  
Fda Approval ◽  
Real World Evidence ◽  
Potential Benefits ◽  
Care System

The 21st Century Cures Act (“Cures Act”) relies on the concept of real-world evidence (“RWE”) to improve the Food and Drug Administration (“FDA”) approval process. This has amplified interest and furthered momentum in applying RWE more broadly, beyond FDA regulation. In this article, we discuss the understandable appeal of RWE's pragmatic application and its many potential benefits. But we also caution that claims about RWE's wide-ranging, ameliorative impact on the health care system are likely overstated.The real world of RWE is messy and uncertain. Successfully incorporating RWE into regular health care system decision-making, beyond the FDA, faces considerable obstacles and limitations. We review the reasons to be wary about RWE as a game-changer. These concerns including data reliability, insufficient incentives for stakeholders to generate and engage with high-quality RWE, and lack of comprehensive regulatory oversight. In addition, the push for RWE may impact the enforcement of the health care fraud and abuse laws, perhaps not in necessarily positive ways. Increased reliance on RWE may have significant implications for off-label fraud enforcement, further conflating the distinction between claims that are false for reimbursement rather than for scientific purposes.

scholarly journals Senior healt-hcare fraud under investigation

2020 ◽  
Vol ahead-of-print (ahead-of-print) ◽  
Author(s):  
Nicole F. Stowell ◽  
Carl Pacini ◽  
Martina K. Schmidt ◽  
Nathan Wadlinger
Keyword(s):  
Health Care ◽  
Health Care Providers ◽  
Well Being ◽  
Care Providers ◽  
Prevention Strategies ◽  
Effective Prevention ◽  
Content Type ◽  
Health Care Fraud ◽  
Increased Risk ◽  
The Usa

Purpose This study aims to increase awareness and educate the reader about health-care fraud targeting seniors in the USA to help stakeholders better understand, recognize and prevent this type of fraud. Design/methodology/approach This paper collects statistics on the current state of health care frauds committed against seniors, and examines related cases and laws. Findings The authors find this type of fraud is highly prevalent and expected to increase. Current laws preventing this fraud from occurring are multifold and complex. While prevention strategies through law enforcement have been somewhat successful, a reduction in resources may put seniors at an increased risk in the years to come. Research limitations/implications Without additional prevention strategies, the problem will likely escalate with a growing population of older adults. This study encourages further research into effective prevention strategies and methods to fight health-care fraud against seniors. Practical implications Health-care fraud and its associated costs pose a significant threat to the society and economy of the USA. Reducing this fraud will not only reduce the costs to the US economy but also improve the physical and mental well-being of senior victims, reduce their mortality and hospitalization rates and improve the public trust placed to health-care providers. Originality/value This study highlights how health-care fraud is committed against seniors. With the projected trend of an aging US population, educating stakeholders, increasing awareness and applying tools to protect seniors will be important to reduce the absolute scope of this problem in the future.

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