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BMC Medical Informatics and Decision Making
Published in: BMC Medical Informatics and Decision Making 1/2023

Open Access 01-12-2023 | Research

Health insurance fraud detection by using an attributed heterogeneous information network with a hierarchical attention mechanism

Authors: Jiangtao Lu, Kaibiao Lin, Ruicong Chen, Min Lin, Xin Chen, Ping Lu

Published in: BMC Medical Informatics and Decision Making | Issue 1/2023

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Abstract

Background

With the rapid growth of healthcare services, health insurance fraud detection has become an important measure to ensure efficient use of public funds. Traditional fraud detection methods have tended to focus on the attributes of a single visit and have ignored the behavioural relationships of multiple visits by patients.

Methods

We propose a health insurance fraud detection model based on a multilevel attention mechanism that we call MHAMFD. Specifically, we use an attributed heterogeneous information network (AHIN) to model different types of objects and their rich attributes and interactions in a healthcare scenario. MHAMFD selects appropriate neighbour nodes based on the behavioural relationships at different levels of a patient’s visit. We also designed a hierarchical attention mechanism to aggregate complex semantic information from the interweaving of different levels of behavioural relationships of patients. This increases the feature representation of objects and makes the model interpretable by identifying the main factors of fraud.

Results

Experimental results using real datasets showed that MHAMFD detected health insurance fraud with better accuracy than existing methods.

Conclusions

Experiment suggests that the behavioral relationships between patients’ multiple visits can also be of great help to detect health care fraud. Subsequent research fraud detection methods can also take into account the different behavioral relationships between patients.
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Metadata
Title
Health insurance fraud detection by using an attributed heterogeneous information network with a hierarchical attention mechanism
Authors
Jiangtao Lu
Kaibiao Lin
Ruicong Chen
Min Lin
Xin Chen
Ping Lu
Publication date
01-12-2023
Publisher
BioMed Central
Published in
BMC Medical Informatics and Decision Making / Issue 1/2023
Electronic ISSN: 1472-6947
DOI
https://doi.org/10.1186/s12911-023-02152-0

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