Abstract
BACKGROUND: Waste and fraud are important problems for health insurers to deal with. With the advent of big data, these insurers are looking more and more towards data mining and machine learning methods to help in detecting waste and fraud. However, labeled data is costly and difficult to acquire as it requires expert investigators and known care providers with atypical behavior. METHODS: In this work we show how recent advances in machine learning can be used to set up a workflow that can aid investigators in discovering practitioners or groups of practitioners with unusual resource use in order to more efficiently combat waste and fraud. We combine three different techniques, which have not been used in the context of healthcare insurance anomaly detection: categorical embeddings to deal with high-cardinality categorical variables, state-of-the-art unsupervised anomaly detection techniques to detect anomalies and Shapley additive explanations (SHAP) to explain the model output. RESULTS: The method has been evaluated on providers with a known anomalous profile and with the help of experts of the largest health insurance fund in Belgium. The quantitative experiments show that categorical embeddings offer a significant improvement compared to standard methods and that the state-of-the-art unsupervised anomaly detection techniques generally show an improvement over traditional methods. In a practical setting, the proposed workflow with SHAP was able to detect a previously unknown, anomalous trend among general practitioners. CONCLUSIONS: The proposed workflow is able to detect known care providers with atypical behaviour and helps expert investigators in making informed decisions concerning possible fraud or overconsumption in the health insurance field.