Meta-analysis of fraud, waste and abuse detection methods in healthcare

Abstract

Fraud, waste and abuse have been a concern in healthcare system due to the exponential increase in the loss of revenue, loss of reputation and goodwill, and a rapid decline in the relationship between healthcare providers and patients. Consequently, fraud, waste and abuse result in a high cost of healthcare services, decreased quality of care, and threat to patients’ lives. Its enormous side effects in healthcare have attracted diverse efforts in the healthcare industry, data analytics industry and research communities towards the development of fraud detection methods. Hence, this study examines and analyzes fraud, waste and abuse detection methods used in healthcare, to reveal the strengths and limitations of each approach. Eighty eight literatures obtained from journal articles, conference proceedings and books based on their relevance to the research problem were reviewed. The result of this review revealed that fraud detection methods are difficult to implement in the healthcare system because new fraud patterns are constantly developed to circumvent fraud detection methods. Research in medical fraud assessment is limited due to data limitations as well as privacy and confidentiality concerns.

Keywords: abuse, fraud, healthcare, waste, fraud detection methods