Graphical Association Analysis for Identifying Variation in Provider Claims for Joint Replacement Surgery.
Stud Health Technol Inform
; 310: 805-809, 2024 Jan 25.
Article
em En
| MEDLINE
| ID: mdl-38269920
ABSTRACT
Identifying potentially fraudulent or wasteful medical insurance claims can be difficult due to the large amounts of data and human effort involved. We applied unsupervised machine learning to construct interpretable models which rank variations in medical provider claiming behaviour in the domain of unilateral joint replacement surgery, using data from the Australian Medicare Benefits Schedule. For each of three surgical procedures reference models of claims for each procedure were constructed and compared analytically to models of individual provider claims. Providers were ranked using a score based on fees for typical claims made in addition to those in the reference model. Evaluation of the results indicated that the top-ranked providers were likely to be unusual in their claiming patterns, with typical claims from outlying providers adding up to 192% to the cost of a procedure. The method is efficient, generalizable to other procedures and, being interpretable, integrates well into existing workflows.
Palavras-chave
Texto completo:
1
Coleções:
01-internacional
Base de dados:
MEDLINE
Assunto principal:
Artroplastia de Substituição
/
Programas Nacionais de Saúde
Tipo de estudo:
Health_economic_evaluation
/
Prognostic_studies
/
Risk_factors_studies
Limite:
Aged
/
Humans
País/Região como assunto:
Oceania
Idioma:
En
Revista:
Stud Health Technol Inform
Assunto da revista:
INFORMATICA MEDICA
/
PESQUISA EM SERVICOS DE SAUDE
Ano de publicação:
2024
Tipo de documento:
Article
País de afiliação:
Austrália
País de publicação:
Holanda