Fraudulent claim detection is one of the greatest challenges the insurance industry faces. Alibaba's return-freight insurance, providing return-shipping postage compensations over product return on the e-commerce platform, receives thousands of potentially fraudulent claims every day. Such deliberate abuse of the insurance policy could lead to heavy financial losses. In order to detect and prevent fraudulent insurance claims, we developed a novel data-driven procedure to identify groups of organized fraudsters, one of the major contributions to financial losses, by learning network information. In this paper, we introduce a device-sharing network among claimants, followed by developing an automated solution for fraud detection based on graph learning algorithms, to separate fraudsters from regular customers and uncover groups of organized fraudsters. This solution applied at Alibaba achieves more than 80% precision while covering 44% more suspicious accounts compared with a previously deployed rule-based classifier after human expert investigations. Our approach can easily and effectively generalizes to other types of insurance.
The insurance industry has been creating innovative products around the emerging online shopping activities. Such e-commerce insurance is designed to protect buyers from potential risks such as impulse purchases and counterfeits. Fraudulent claims towards online insurance typically involve multiple parties such as buyers, sellers, and express companies, and they could lead to heavy financial losses. In order to uncover the relations behind organized fraudsters and detect fraudulent claims, we developed a large-scale insurance fraud detection system, i.e., InfDetect, which provides interfaces f…
Skoltech（斯科尔科沃科学技术研究所）；University of Hamburg（汉堡大学）
Fraud causes substantial costs and losses for companies and clients in the finance and insurance industries. Examples are fraudulent credit card transactions or fraudulent claims. It has been estimated that roughly $10$ percent of the insurance industry's incurred losses and loss adjustment expenses each year stem from fraudulent claims. The rise and proliferation of digitization in finance and insurance have lead to big data sets, consisting in particular of text data, which can be used for fraud detection. In this paper, we propose architectures for text embeddings via deep learning, which h…
Centre for Artificial Intelligence and Machine Learning Institute for Development and Research in Banking Technology（人工智能与机器学习中心，银行技术发展与研究院）
Of late, insurance fraud detection has assumed immense significance owing to the huge financial & reputational losses fraud entails and the phenomenal success of the fraud detection techniques. Insurance is majorly divided into two categories: (i) Life and (ii) Non-life. Non-life insurance in turn includes health insurance and auto insurance among other things. In either of the categories, the fraud detection techniques should be designed in such a way that they capture as many fraudulent transactions as possible. Owing to the rarity of fraudulent transactions, in this paper, we propose a chao…
Sri Sathya Sai Institute of Higher Learning（萨提亚赛高等学习学院）
Fraud has led to a huge addition of expenses in health insurance sector in India. The work is aimed to provide methods applied to health insurance fraud detection. The work presents two approaches - a markov model and an improved markov model using gradient boosting method in health insurance claims. The dataset 382,587 claims of which 38,082 claims are fraudulent. The markov based model gave the accuracy of 94.07% with F1-score at 0.6683. However, the improved markov model performed much better in comparison with the accuracy of 97.10% and F1-score of 0.8546. It was observed that the improved…
In the insurance industry detecting fraudulent claims is a critical task with a significant financial impact. A common strategy to identify fraudulent claims is looking for inconsistencies in the supporting evidence. However, this is a laborious and cognitively heavy task for human experts as insurance claims typically come with a plethora of data from different modalities (e.g. images, text and metadata). To overcome this challenge, the research community has focused on multimodal machine learning frameworks that can efficiently reason through multiple data sources. Despite recent advances in…
Inductive inference of gradient-boosted decision trees on graphs for insurance fraud detection
Data Office, Allianz Benelux（Allianz Benelux 数据办公室）；KU Leuven University of Antwerp-imec（安特卫普-imec 联合大学KU Leuven）；KU Leuven；University of Antwerp-imec（安特卫普-imec 大学）
Indian Institute of Information Technology Allahabad（印度阿拉哈巴德信息技术学院）；Shiksha ‘O’ Anusandhan（悉克沙奥阿努桑德汉大学）
With healthcare being critical aspect, health insurance has become an important scheme in minimizing medical expenses. Following this, the healthcare industry has seen a significant increase in fraudulent activities owing to increased insurance, and fraud has become a significant contributor to rising medical care expenses, although its impact can be mitigated using fraud detection techniques. To detect fraud, machine learning techniques are used. The Centers for Medicaid and Medicare Services (CMS) of the United States federal government released "Medicare Part D" insurance claims is utilized…
The insurance industry, with its large datasets, is a natural place to use big data solutions. However it must be stressed, that significant number of applications for machine learning in insurance industry, like fraud detection or claim prediction, deals with the problem of machine learning on an imbalanced data set. This is due to the fact that frauds or claims are rare events when compared with the entire population of drivers. The problem of imbalanced learning is often hard to overcome. Therefore, the main goal of this work is to present and apply various methods of dealing with an imbala…
University of Birjand（比尔詹德大学）；University of New Brunswick（新不伦瑞克大学）
Fraud detection is an important topic that applies to various enterprises such as banking and financial sectors, insurance, government agencies, law enforcement, and more. Fraud attempts have been risen remarkably in current years, shaping fraud detection an essential topic for research. One of the main challenges in fraud detection is acquiring fraud samples which is a complex and challenging task. In order to deal with this challenge, we apply one-class classification methods such as SVDD which does not need the fraud samples for training. Also, we present our algorithm REDBSCAN which is an …
Insurance companies must manage millions of claims per year. While most of these claims are non-fraudulent, fraud detection is core for insurance companies. The ultimate goal is a predictive model to single out the fraudulent claims and pay out the non-fraudulent ones immediately. Modern machine learning methods are well suited for this kind of problem. Health care claims often have a data structure that is hierarchical and of variable length. We propose one model based on piecewise feed forward neural networks (deep learning) and another model based on self-attention neural networks for the t…
Eindhoven University of Technology（埃因霍温理工大学）；Achmea BV（Achmea公司）
Fraud detection is a difficult problem that can benefit from predictive modeling. However, the verification of a prediction is challenging; for a single insurance policy, the model only provides a prediction score. We present a case study where we reflect on different instance-level model explanation techniques to aid a fraud detection team in their work. To this end, we designed two novel dashboards combining various state-of-the-art explanation techniques. These enable the domain expert to analyze and understand predictions, dramatically speeding up the process of filtering potential fraud c…
Skolkovo Institute of Science and Technology（斯科尔科沃科学技术研究院）
Fraud in healthcare is widespread, as doctors could prescribe unnecessary treatments to increase bills. Insurance companies want to detect these anomalous fraudulent bills and reduce their losses. Traditional fraud detection methods use expert rules and manual data processing. Recently, machine learning techniques automate this process, but hand-labeled data is extremely costly and usually out of date. We propose a machine learning model that automates fraud detection in an unsupervised way. Two deep learning approaches include LSTM neural network for prediction next patient visit and a seq2se…
The US federal government spends more than a trillion dollars per year on health care, largely provided by private third parties and reimbursed by the government. A major concern in this system is overbilling, waste and fraud by providers, who face incentives to misreport on their claims in order to receive higher payments. In this paper, we develop novel machine learning tools to identify providers that overbill Medicare, the US federal health insurance program for elderly adults and the disabled. Using large-scale Medicare claims data, we identify patterns consistent with fraud or overbillin…
Institute for Development and Research in Banking Technology (IDRBT)（银行技术发展与研究所）；University of Hyderabad（海得拉巴大学）
Of late, in order to have better acceptability among various domain, researchers have argued that machine intelligence algorithms must be able to provide explanations that humans can understand causally. This aspect, also known as causability, achieves a specific level of human-level explainability. A specific class of algorithms known as counterfactuals may be able to provide causability. In statistics, causality has been studied and applied for many years, but not in great detail in artificial intelligence (AI). In a first-of-its-kind study, we employed the principles of causal inference to …
The UK anti-fraud charity Fraud Advisory Panel (FAP) in their review of 2016 estimates business costs of fraud at 144 billion, and its individual counterpart at 9.7 billion. Banking, insurance, manufacturing, and government are the most common industries affected by fraud activities. Designing an efficient fraud detection system could avoid losing the money; however, building this system is challenging due to many difficult problems, e.g.imbalanced data, computing costs, etc. Over the last three decades, there are various research relates to fraud detection but no agreement on what is the best…
Insurance fraud occurs when policyholders file claims that are exaggerated or based on intentional damages. This contribution develops a fraud detection strategy by extracting insightful information from the social network of a claim. First, we construct a network by linking claims with all their involved parties, including the policyholders, brokers, experts, and garages. Next, we establish fraud as a social phenomenon in the network and use the BiRank algorithm with a fraud specific query vector to compute a fraud score for each claim. From the network, we extract features related to the fra…
Medicare fraud results in considerable losses for governments and insurance companies and results in higher premiums from clients. Medicare fraud costs around 13 billion euros in Europe and between 21 billion and 71 billion US dollars per year in the United States. This study aims to use artificial neural network based classifiers to predict medicare fraud. The main difficulty using machine learning techniques in fraud detection or more generally anomaly detection is that the data sets are highly imbalanced. To detect medicare frauds, we propose a multiple inputs deep neural network based clas…
An Attack Method for Medical Insurance Claim Fraud Detection based on Generative Adversarial Network
Department of Mathematics, Hong Kong Baptist University, Kowloon Tong, Hong Kong（香港 Baptist 大学数学系）；Tsinghua Shenzhen International Graduate School , Tsinghua University, Shenzhen 518055, China（清华大学深圳国际研究生院）
Tarleton Analytics Institute, Tarleton State University（塔尔顿州立大学塔尔顿分析研究所）；Tarleton State University（塔尔顿州立大学）
Improper health insurance payments resulting from fraud and upcoding result in tens of billions of dollars in excess health care costs annually in the United States, motivating machine learning researchers to build anomaly detection models for health insurance claims. This article describes two such strategies specifically for ER claims. The first is an upcoding model based on severity code distributions, stratified by hierarchical diagnosis code clusters. A statistically significant difference in mean upcoding anomaly scores is observed between free-standing ERs and acute care hospitals, with…
Year-over-Year Developments in Financial Fraud Detection via Deep Learning: A Systematic Literature Review
Georgia Institute of Technology, College of Computing（佐治亚理工学院计算机学院）；Harvard University, School of Engineering and Applied Sciences（哈佛大学工程与应用科学学院）；University of Illinois Urbana-Champaign（伊利诺伊大学厄巴纳-香槟分校）；Columbia University, The Fu Foundation School of Engineering and Applied Science（哥伦比亚大学傅以文工程与应用科学学院）
Blockchain technology has piqued the interest of businesses of all types, while consistently improving and adapting to developers and business owners requirements. Therefore, several blockchain platforms have emerged, making it challenging to select a suitable one for a specific type of business. This paper presents a classification of over one hundred blockchain platforms. We develop smart contracts for detecting healthcare insurance frauds using two blockchain platforms selected based on our proposed decision-making map approach for the selection of the top two suitable platforms for healthc…
TU Kaiserslautern（凯泽斯劳滕工业大学）；Fraunhofer ITWM（弗劳恩霍夫工业数学研究所）
In this paper, we introduce the Vehicle Claims dataset, consisting of fraudulent insurance claims for automotive repairs. The data belongs to the more broad category of Auditing data, which includes also Journals and Network Intrusion data. Insurance claim data are distinctively different from other auditing data (such as network intrusion data) in their high number of categorical attributes. We tackle the common problem of missing benchmark datasets for anomaly detection: datasets are mostly confidential, and the public tabular datasets do not contain relevant and sufficient categorical attri…
University of Colorado at Boulder（科罗拉多大学博尔德分校）；University of Maryland, College Park（马里兰大学帕克分校）；IUPUI（印第安纳大学与普渡大学印第安纳波利斯联合分校）
Detecting anomalous activity in human mobility data has a number of applications including road hazard sensing, telematic based insurance, and fraud detection in taxi services and ride sharing. In this paper we address two challenges that arise in the study of anomalous human trajectories: 1) a lack of ground truth data on what defines an anomaly and 2) the dependence of existing methods on significant pre-processing and feature engineering. While generative adversarial networks seem like a natural fit for addressing these challenges, we find that existing GAN based anomaly detection algorithm…
