Pharmacy Claims Fraud Detection Using Apache Spark

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Up to 10% of the pharmacy claims submitted to health plans and insurance companies are estimated to be fraudulent. A two-step process comprising of a combination of unsupervised and supervised learning techniques can be used to effectively identify the Fraud, Waste and Abuse in the Pharmacy industry. Claims submitted by the pharmacies to insurance companies/health plans provide data rich in valuable insights that enable prediction of fraud, waste and abuse. Suspicious activity can be identified by detecting anomalies in the data using unsupervised techniques like clustering, univariate and multi-variate outlier analysis, link analysis, simulated fraud signatures, etc.

With known fraud, waste and abuse data, supervised learning techniques like Random Forest, Neural Networks, etc., can be used to identify fraudulent transactions similar to historical fraud signatures. Combining outputs of these techniques Fraud scores are generated for each player [member, pharmacy and prescriber].

In this talk, we’re going to illustrate how machine learning [Spark MLLib and GraphX] was used to identify suspicious activity like co-conspiracies to commit fraud by pharmacies and prescribers[doctors] and others. We’re also going to demonstrate how fraud score was determined in this pharmacy claims fraud detection application.

Session hashtag: #DS9SAIS

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About Rajesh Inbasekaran

Rajesh is the CTO of Kavi Global, a consulting services, software and solutions company. Rajesh has two decades of experience in advanced analytics and information technology, specializing in data engineering, data science and visualization, machine learning and artificial intelligence. Rajesh has led award winning enterprise data analytics initiatives at GE and fortune 500 companies across industries, and created patented next gen data and analytics tools. Before the launch of Kavi Global, Rajesh led the award-winning GE Rail Services Analytics team from GENPACT Analytics, an entity formerly owned by GE. Rajesh holds an MBA in Marketing and Systems from Bharathidasan Institute of Management in Trichy, India, and a Bachelor of Commerce degree from University of Madras in Chennai, India.

About Giridharan Gurumoorthy

Giridharan Gurumoorthy is a Business Analytics Senior Consultant at Kavi Global LLC. He has more than a decade of experience in the healthcare industry and advanced analytics technology. He also has published several papers in data analytics and its applications.