Characterizing healthcare provider, claim, beneficiary and healthcare merchant normal behavior using non-parametric statistical outlier detection scoring techniques

Abstract

This invention uses non-parametric statistical measures and probability mathematical techniques to calculate deviations of variable values, on both the high and low side of a data distribution, from the midpoint of the data distribution. It transforms the data values and then combines all of the individual variable values into a single scalar value that is a “good-ness” score. This “good-ness” behavior score model characterizes “normal” or typical behavior, rather than predicting fraudulent, abusive, or “bad”, behavior. The “good” score is a measure of how likely it is that the subject's behavior characteristics are from a population representing a “good” or “normal” provider, claim, beneficiary or healthcare merchant behavior. The “good” score can replace or compliment a score model that predicts “bad” behavior in order to reduce false positive rates. The optimal risk management prevention program should include both a “good” behavior score model and a “bad” behavior score model.

Dependencies are inferred from the claim text.