U.S. flag
      An official website of the United States government, Department of Justice.
        Here's how you know
      Here's how you know**Official websites use .gov**
            
            A **.gov** website belongs to an official government organization in the United States.
      **Secure .gov websites use HTTPS**
            
            A **lock** (
            A locked padlock
            ) or **https://** means you’ve safely connected to the .gov website. Share sensitive information only on official, secure websites. Menu

      
        close

            
            
                                              About NIJ
        
                    
  
          About NIJ
      
    
          The NIJ Director
          How NIJ Is Organized
          Mission and Guiding Principles
          Research and Development Process
          Strategic Framework
          Assessments of NIJ
          Annual Reports & Reports to Congress
          Staff Directory
          Funding & Awards
        
                    
  
          Funding & Awards
      
    
          Current Funding
          Forthcoming Funding
          Expired Funding
          Awards: Listing of Funded Projects
          Guidance for Applicants and Awardees
          Fellowship & Student Programs
          Travel Scholarships
          NIJ Challenge Program
          Library & Multimedia
        
                    
  
          Library & Multimedia
      
    
          NIJ Journal
          Podcasts
          Publications Listing
          Multimedia Listing
          Rated Practices on CrimeSolutions
          Rated Programs on CrimeSolutions
          Software & Databases
          Datasets
          Patents
          Topics
        
                    
  
          Topics
      
    
          Article Listing
          Corrections
          Courts
          Crime Prevention
          Crimes
          Drugs and Crime
          Equipment and Technology
          Forensic Sciences
          Youth Justice
          Justice System Reform
          Law Enforcement
          Tribal Crime and Justice
          Victims of Crime
          Events
        
                    
  
          Events
      
    
          NIJ 2024 Research Conference
          Scheduled Events
          On-Demand Events
          Research Meetings & Workshops
          NIJ-Hosted Online Training

                            
                                About
          Contact Us
          Subscribe
          Topics A-Z
                  Share
FacebookXLinkedInRedditPinterestEmail Home
                            Library & Multimedia
 Using Physician Behavioral Big Data for High Precision Fraud Prediction and Detection
NCJ Number
              306161

Author(s)
          Sally S. Simpson;
                        Ritu Agarwal;
                        Guodong (Gordon) Gao
Date Published

2022
Length
              15 pages
Annotation
              This summary report discusses a project that aimed to provide new policy-relevant applications by using state-of-the-art data science to improve risk assessment of physician engagement in fraud.
Abstract
              The authors of this summary report present the results of a project that sought to answer three research questions: if models that use big data on non-clinical physician behavior, such as patient complaints or life stressors, can successfully predict engagement in fraud in the near-term future, approximately one to five years; which of those non-clinical behavioral factors would represent the greatest risk for fraud engagement; and which machine learning algorithm would be most accurate in predicting a physician’s risk of engaging in fraud. To answer those three questions, the researchers relied on techniques that used behavioral big data and deployed state-of-the-art data analytic tools to detect the risk of Medicare fraud early on, before payment, and potentially early enough to prevent the fraud from occurring. The researchers investigated two kinds of models, predictive and explanatory; their main predictive modeling findings revealed a high degree of performance accuracy up to five years prior to the exclusion year; the explanatory models indicated that factors associated with high risks of fraud included a prior criminal case, tax liens, property purchases, gifts from companies, and one-star online reviews. Both sets of results pointed to the utility of using nonclinical data in fraud prevention and control efforts.
      
  
          Additional Details
Grant Number(s)
        2019-R2-CX-0016


  
  
        
  Agencies
        NIJ-Sponsored


  
  
        
  Publication Type
        Report (Summary)


  
  
        
  Award
        Using Physician Behavioral Big Data for High Precision Fraud Prediction and Detections
    
  
  
Date Published: January 1, 2022
    
          Downloads
        
                      PDF

Side navigation
  

        

  
  
              NIJ Journal
    
      
            
            
            
      Podcasts
    
      
            
            
            
      Publications Listing
    
      
            
            
            
      Multimedia Listing
    
      
            
            
            
      Rated Practices on CrimeSolutions
    
      
            
            
            
      Rated Programs on CrimeSolutions
    
      
            
            
            
      Software & Databases
    
      
            
            
            
      Datasets
    
      
            
            
            
      PatentsRelated Topics
        
                Medicaid/Medicare fraud
        Fraud



  
Similar Publications
        
                      The Problem with Criminal Records: Discrepancies between State Reports and Private-sector Background Checks
                  What’s Known and Unknown About Marijuana (Part Two)
                  Identifying COVID-19 Policies and Practice that Juvenile Justice Systems Should Maintain Long-Term: Listening Session 6: Juvenile Court Judges
 Top

      National Institute of Justice

        
        
                        About NIJ
                    About NIJ
      
    
                  How NIJ Is Organized
      
    
                  NIJ Director
      
    
                  Research Disclaimer
      
    
                  Funding & Awards
                    Funding & Awards Home
      
    
                  Awards Listing
      
    
                  Current Funding
      
    
                  Guidance for Applicants and Awardees
      
    
                  Resources
                    Events
      
    
                  Podcasts
      
    
                  Publications
      
    
                  Topics
      
    
                  Multimedia
      
    
                  Reuse Policy
      
    
                  Contacts
                    Contact NIJ
      
    
                  Staff Directory
      
    
                  Submit a FOIA Request
      
    
                  File a Civil Rights ComplaintFacebook
          
                      X
          
                      YouTube
  

      810 7th St. NW, Washington, D.C. 20531
      
              Secondary Footer link menu
            Accessibility
              Plain Language
              Privacy Policy
              Legal Policies and Disclaimer
              No FEAR Act
              Freedom of Information Act
              USA.gov
              Justice.gov