Medical Fraud and Abuse Detection System Based on Machine Learning

It is estimated that approximately 10% of healthcare system expenditures are wasted due to medical fraud and abuse. In the medical area, the combination of thousands of drugs and diseases make the supervision of health care more difficult. To quantify the disease–drug relationship into relationship score and do anomaly detection based on this relationship score and other features, we proposed a neural network with fully connected layers and sparse convolution. We introduced a focal-loss function to adapt to the data imbalance and a relative probability score to measure the model’s performance. As our model performs much better than previous ones, it can well alleviate analysts’ work.