Detecting Healthcare Billing Anomalies with Graph Neural Networks
DOI:
https://doi.org/10.5281/zenodo.20744309Keywords:
Healthcare Payment Integrity, Fraud Waste and Abuse Detection, Unsupervised Machine Learning, Graph-Based Anomaly Detection, Payer–Provider Network Analytics, Billing Pattern Analysis, Medicaid Payment Oversight, Healthcare Claims Analytics, Encounter-Level Fraud Detection, Normalized Payment Amount Modeling, Data-Driven Healthcare Compliance, Subrogation Data Integration, Network-Based Risk Scoring, Real-Time Payment Monitoring, Public Healthcare Program Integrity.Abstract
Healthcare payment accuracy directly influences both cost and quality of care, yet high rates of fraud, waste, and abuse continue to persist. These challenges are exacerbated by the inherent complexity and lack of transparency surrounding payment analytics. Addressing these issues, this study proposes an effective, data-driven solution for detecting potentially fraudulent or erroneous billing practices, using unsupervised machine learning to analyze payer-provider relationships. The primary motivation is threefold: first, such unsupervised approaches eliminate the need for a labeled training set; second, they take advantage of the richness and heterogeneity of the data, including subrogation and encounter information; and third, they have no bias toward any specific type of anomaly.
Core methodological contributions include the novel application of unsupervised and graph-based methods for billing analysis and anomaly detection, and the integration of external data into traditional billing tables to uncover new patterns. Testing demonstrates that model-enriched Normalized Payment Amount can help identify fraudulent encounters, offering long-term potential for both real-time monitoring and assisting state-level agencies responsible for managing Medicaid-funded healthcare.
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