US 2025/0156957 A1 · SYSTEMS AND METHODS FOR MEDICAL FRAUD DETECTION

Abstract

Systems and methods are disclosed for determining fraudulent entities. The method includes retrieving characteristics data associated with known fraudulent entities. A first graph is generated based on the characteristics data associated with the known fraudulent entities, the first graph represents relationships among the fraudulent entities and related entities of the known fraudulent entities. Identification data associated with a target entity is received. Characteristics data associated with the target entity is retrieved using the identification data. A second graph is generated based on the characteristics data associated with the target entity, the second graph represents relationships among the target entity and related entities of the target entity. The first graph and the second graph are compared to generate an association score for the target entity. Investigative targets are determined based on the association score. A presentation of the investigative targets is displayed via a graphical user interface of a device.

Claims20

Dependent claims

A computer-implemented method comprising:

receiving, by one or more processors, one or more resource requests associated with a target entity;
generating, by the one or more processors, a first graph based on first characteristics data associated with one or more known fraudulent entities, wherein the first graph includes one or more first nodes that respectively represent the one or more known fraudulent entities;
generating, by the one or more processors, a second graph based on second characteristics data associated with the target entity, wherein the second graph includes a second node that represents the target entity;
generating, by the one or more processors, an association score for the target entity by measuring a degree of association between the first graph and the second graph;
determining, by the one or more processors, whether the target entity is an investigative target based on the association score;
and
generating, by the one or more processors and upon determining that the target entity is the investigative target, computer-executable instructions to invalidate the one or more resource requests associated with the target entity.

4 more elements

A system comprising:

one or more processors;
and
one or more non-transitory computer readable media storing instructions which, when executed by the one or more processors, cause the one or more processors to:
receiving one or more resource requests associated with a target entity;
generating a first graph based on first characteristics data associated with one or more known fraudulent entities, wherein the first graph includes one or more first nodes that respectively represent the one or more known fraudulent entities;
generating a second graph based on second characteristics data associated with the target entity, wherein the second graph includes a second node that represents the target entity;
generating an association score for the target entity by measuring a degree of association between the first graph and the second graph;
determining whether the target entity is an investigative target based on the association score;
and
generating, upon determining that the target entity is the investigative target, computer-executable instructions to invalidate the one or more resource requests associated with the target entity.

7 more elements

One or more non-transitory computer readable media storing instructions which, when executed by one or more processors of a computing system, cause the one or more processors to perform operations comprising:

receiving one or more resource requests associated with a target entity;
generating a first graph based on first characteristics data associated with one or more known fraudulent entities, wherein the first graph includes one or more first nodes that respectively represent the one or more known fraudulent entities;
generating a second graph based on second characteristics data associated with the target entity, wherein the second graph includes a second node that represents the target entity;
generating an association score for the target entity by measuring a degree of association between the first graph and the second graph;
determining whether the target entity is an investigative target based on the association score;
and
generating, upon determining that the target entity is the investigative target, computer-executable instructions to invalidate the one or more resource requests associated with the target entity.

4 more elements

Dependencies are inferred from the claim text.

Systems and methods for medical fraud detection

Life of this patent

Systems and methods for medical fraud detection

Life of this patent

Abstract

Claims20