Korean J Prev Med.  2003 May;36(2):147-152.

Efficient DRG Fraud Candidate Detection Method Using Data Mining Techniques

• Hong D
• Lee JK
• Jo MW
• Park K
• Lee SI
• Lee MS
• Kim CY
• Kim YI

Abstract

OBJECTIVES
To develop a Diagnosis-Related Group (DRG) fraud candidate detection method, using data mining techniques, and to examine the efficiency of the developed method. METHODS: The study included 79, 790 DRGs and their related claims of 8 disease groups (Lens procedures, with or without, vitrectomy, tonsillectomy and/or adenoidectomy only, appendectomy, Cesarean section, vaginal delivery, anal and/or perianal procedures, inguinal and/or femoral hernia procedures, uterine and/or adnexa procedures for nonmalignancy), which were examined manually during a 32 months period. To construct an optimal prediction model, 38 variables were applied, and the correction rate and lift value of 3 models (decision tree, logistic regression, neural network) compared. The analyses were performed separately by disease group. RESULTS: The correction rates of the developed method, using data mining techniques, were 15.4 to 81.9%, according to disease groups, with an overall correction rate of 60.7%. The lift values were 1.9 to 7.3 according to disease groups, with an overall lift value of 4.1. CONCLUSIONS: The above findings suggested that the applying of data mining techniques is necessary to improve the efficiency of DRG fraud candidate detection.

Keyword

Diagnosis-Related Groups; Fraud; Decision trees; Neural networks

MeSH Terms

Adenoidectomy
Appendectomy
Cesarean Section
Data Mining*
Decision Trees
Diagnosis-Related Groups*
Female
Fraud*
Hernia, Femoral
Logistic Models
Methods*
Pregnancy
Tonsillectomy
Trees
Vitrectomy