A scoring model to detect abusive billing patterns in health insurance claims

We propose a scoring model that detects outpatient clinics with abusive utilization patterns based on profiling information extracted from electronic insurance claims. The model consists of (1) scoring to quantify the degree of abusiveness and (2) segmentation to categorize the problematic providers with similar utilization patterns. We performed the modeling for 3705 Korean internal medicine clinics. We applied data from practitioner claims...