Medical Knowledge Graph to Enhance Fraud, Waste, and Abuse Detection on Claim Data: Model Development and Performance Evaluation

BACKGROUND: Fraud, Waste, and Abuse (FWA) detection is a significant yet challenging problem in the health insurance industry. An essential step in FWA detection is to check whether the medication is clinically reasonable with respect to the diagnosis. Currently, human experts with sufficient medical knowledge are required to perform this task. To reduce the cost, insurance inspectors tend to build an intelligent system to detect suspicious claims with inappropriate diagnoses/medications automatically. OBJECTIVE: The aim of this study was to develop an automated method for making use of a medical knowledge graph to identify clinically suspected claims for FWA detection. METHODS: First, we identified the medical knowledge that is required to assess the clinical rationality of the claims. We then searched for data sources that contain information to build such knowledge. In this study, we focused on Chinese medical knowledge. Second, we constructed a medical knowledge graph using unstructured knowledge. We used a deep learning–based method to extract the entities and relationships from the knowledge sources and developed a multilevel similarity matching approach to conduct the entity linking. To guarantee the quality of the medical knowledge graph, we involved human experts to review the entity and relationships with lower confidence. These reviewed results could be used to further improve the machine-learning models. Finally, we developed the rules to identify the suspected claims by reasoning according to the medical knowledge graph. RESULTS: We collected 185,796 drug labels from the China Food and Drug Administration, 3390 types of disease information from medical textbooks (eg, symptoms, diagnosis, treatment, and prognosis), and information from 5272 examinations as the knowledge sources. The final medical knowledge graph includes 1,616,549 nodes and 5,963,444 edges. We designed three knowledge graph reasoning rules to identify three kinds of inappropriate diagnosis/medications. The experimental results showed that the medical knowledge graph helps to detect 70% of the suspected claims. CONCLUSIONS: The medical knowledge graph–based method successfully identified suspected cases of FWA (such as fraud diagnosis, excess prescription, and irrational prescription) from the claim documents, which helped to improve the efficiency of claim processing.