HealthcareFraud Executive Summary

Medicare fraud costs taxpayers money and diminishes the legitimacy of an emerging universal health care in the USA

Impact of Medicare fraud is wide and involves medical-based organizations including hospitals, drug manufacturers, insurance providers, as well as small practice medical professionals

Medicare fraud detection is urgently needed to stop the hemorrhaging of millions of wasted dollars  

Pulse Insights took on the challenge and successfully developed a data analytics tool to predict Medicare fraud before it happens

Problem Statement

Identify the existence of fraudulent prescriptions initiated by the physician

Fraudulent is defined as a prescription pattern that matches a prescription pattern of a known physician who is identified on the ## List of Excluded Individuals and Entities

Our primary tree split was based on town and then provider type

This primarily reflected smaller towns with few providers, which captured a good proportion of the fraud

A second major split was on state, with certain states accounting for a greater percentage of the fraud, particularly, Florida, ## North Carolina, Montana, and Colorado

Our results could be improved by creating a specialty level model of doctor with prescribing habits indicated as ratios of overall prescriptions.

Conclusions

Our mission to build a Medicare fraud detection tool was successful

Incorporated cutting-edge data science analytics�

The tool showcases our firm’s analytical and modelling capabilities in the big data sector�

Fraud detection is a fruitful application that can be applied to critical fields including medicine, insurance, banking, etc�

Physician fraud can be observed not only from a doctor-pharmaceutical tier but from a prescription-doctor tier