1) The document discusses using various machine learning and predictive analytics techniques like random forests, support vector machines, neural networks, and network analysis to analyze healthcare claims data and detect anomalies and fraud. 2) Over 87 million claim lines from 17,000 providers and 1.6 million members are analyzed monthly using 70 measures of claiming behavior and 6 algorithms. Small clusters of providers with high-risk claiming patterns are identified. 3) Random forest classification and support vector machines are used to predict which investigations will yield findings, and random forests provide a measure of variable importance. Network analysis can reveal problematic relationships between providers and members.

1. Claim Pattern Anomalies
Making a Mole Hill Out of a Mountain
Predictive Analytics World for Business
San Francisco
May 17, 2017
CAS Analytics & Data Provisioning Team v01
Darryl Humphrey, PhD, PMP
linkedin.com/in/dghumphrey1

2. Provider and member claiming behavior is
affected by many factors.
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FraudAnalytics
Member and
Provider
Claiming
Patterns are
Dynamic
Economic Conditions
Plan Design
Policies and Processes
Compliance Verification
Industry Realities

3. Analyzing equivalent of 87,000,000 claim lines
monthly encompassing 17,000 providers and
1.6 million members.
–Nine (9) practice
areas across health,
dental, and pharmacy
benefits
–70 measures of
claiming behavior
–Six (6) algorithms
–Look for converging
results
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4. Multi-variate distance measure identifies providers
whose claiming patterns differ from the population.
ProportionofTotal$
AssociatedwithRiskyClaims
0
.2.4.6.8
1
0 50 100 150
DrugRD
Non Outlier MCD Outlier
November Analytic Run
All providers reviewed
4.18
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5. 0
.2.4.6.8
1
0 50 100 150
DrugRD
Cluster 1 Cluster 2 Cluster 3 Cluster 4
Cluster 5 Cluster 6 Cluster 7 Cluster 8
November Analytic Run
All Providers reviewed kmeans results
Clustering algorithm sharpens the focus on the
riskiest providers.
4.18
Providers that cluster together have similar claiming patterns.
24
5
54
n=34
Small clusters
with high RD
scores are of most
interest.
ProportionofTotal$
thatareatRisk
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6. CAS ADP Team 6
Reviewing the cluster characteristics gives insight into what
claiming patterns are driving the outlier scores.
Mean Z Scores
Cluster # Prvr
Avg
DrugRD
Var1 Var2 Var3 Var4 Var5 Var6 Var7 Var8 Var9
4 5 24 2.0 29.7 -0.5 -0.1 0.1 -0.4 -0.2 -0.2 -0.5
2 24 14 -0.1 0.8 10.3 1.7 1.7 -0.3 0.3 0.6 0.7
3 34 84 -1.3 0.8 -0.4 36.8 8.4 8.9 4.3 0.5 1.1
5 54 46 -0.4 0.9 0.9 17.1 3.4 1.9 2.5 0.9 0.5
…
1 682 2.15 0.2 0.0 0.2 -0.3 0.0 -0.2 -0.1 -0.2 0.2

7. CAS ADP Team 7
Claim-specific risk is estimated for the variables highlighted in
the K-means and MCD analyses.
RiskMA(i,j) = (e-(MA(i,j)/Max
MA
(i)) * (1-di(j)/r))-e-1)/(1-e-1)
Limited investigation resources are targeted on the specific claims
most likely to be an issue.

8. Network analysis can reveal relationships that warrant
further investigation.
Collusion between members
and suspect providers?
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Problematic providers tend to
have customers in common.

9. Claiming patterns for narcotics are of particular
interest.
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Highly concentrated business
relationships are flagged.
Are members seeking narcotics from
multiple doctors and pharmacies?

10. Machine learning (ML) = architectures for building
algorithms that learn.
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mA
SVM
Random
Forest
NN
Neural
Network
CNNDBN
Deep Learning
RBM
K-NN
RNN
Machine Learning

11. Random Forest algorithm classifies observations based
on the majority vote of many decision trees.
Risk classification
…
1200 obs
7 vars
Sample
with
replacement
Sample
with
replacement
Sample
with
replacement
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12. Random Forest technique shows promise in predicting
which investigations will yield findings of note.
1 0
1 25 9
0 1 50
True Positive Rate: 74%
True Negative Rate: 98%
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RiskMA(i,j) = (e-(MA(i,j)/Max
MA
(i)) * (1-di(j)/r))-e-1)/(1-e-1)

13. Random Forest provides a measure of a variable’s
importance to classification success.
Var 6
Var 2
Var 3
Var 4
Var 1
Var 5
Var 7
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14. Automated review of receipts provides early detection
of potential issues.
Machine learning algorithm is being used to
determine if the document is a valid receipt.
Data lift technology extracts
the information.

15. Analytics is one input used to match cost-to-investigate
with the anticipated ROI.
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16. There are many paths to generating ROI from
fraud detection analytics.
– Business knowledge and a
willingness to learn are more
important than the tool set
– Analytics are tools; keep them
sharp
– Verify that the analyses are:
– Relevant
– Reliable
– Responsible
– Tailor audit investigations to
the nature and magnitude of
the risk
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17. Jil Tanguay, BSc (Spec), CFI, CRMA
Manager
Claims Assurance Services
Alberta Blue Cross
jtanguay@ab.bluecross.ca
Darryl Humphrey, PhD, PMP
Senior Data Scientist
Claims Assurance Services
Alberta Blue Cross
dhumphrey@ab.bluecross.ca
Yemi Dare-Ode, BSc
Nazanin Tahmasebi, PhD
Wesley Wood, Bsc
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18. Random forest classification accuracy stabilizes at
approximately 220 trees.
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19. Many data sets contain nonlinear relationships which can
reduce the effectiveness of some detection methods.
– Datasets that are linearly
separable with some noise work
out great
0 x
0 x
0
x2
x
– Some data sets aren’t linear in
their initial state
– The data can be mapped to a
higher-dimensional space
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20. Map feature space to one of higher dimensionality
where the training set is linearly separable.
Φ: x → φ(x)
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21. Support Vector Machines find the
optimal surface that separates the
groups.
– Maximizes the distance between the
hyperplane and the “difficult points”
close to decision boundary
– If there are no points near the decision
surface, then there will be fewer false
positives and false negatives
– Support vectors are the observations
near the decision boundary that
contribute to determining the boundary.
– Implies that only support vectors matter;
other training examples are ignorable
Ch. 15
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22. RD QuintileRD Quintile
Random Forest Confusion Matrix
Quintile Accuracy
0-0.20 0.80
0.20-0.40 0.67
0.40-0.60 0.50
0.60-0.80 0.69
0.80 -1 0.91
Quintile Accuracy
0-0.20 0.85
0.20-0.40 0.54
0.40-0.60 0.54
0.60-0.80 0.67
0.80 -1 0.94
SVM Confusion Matrix
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23. – Artificial neural networks are
composed of multiple nodes
which imitate neurons of the
human brain.
Neural networks are well-suited to detection tasks.
– Neurons are connected by links
and they interact with each
other. Each link is associated
with a weight
– Artificial neural networks learn
by modifying the weights in
response to feedback
– Deep learning = lots of hidden
layers
– Most often used for images
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24. Eye movement research indicates that we recognize
objects by extracting features.
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25. The series of layers between input & output do
feature extraction and processing in stages, just as our
brains do.
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Learning
Variables

26. Network analysis is used to show the effect of
ownership on a pharmacy’s claiming behavior.
– Assertion is that company policy /
implicit guidelines can drive
claiming behavior across the
pharmacies owned by a single
corporate entity
– Network defined by pharmacies
registered with the same legal name
– Red = high total $ from risky claiming
relative to other pharmacies
– Large = high proportion of a
pharmacy’s $ from risky claiming
– Close together = similar high total $
at risk
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