Discovering Self-referral between Doctors and Pharmacists Based on Network Mining

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Askarzadeh Hassan; TAROKH MOHAMMAD JAFAR

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Journal: HEALTH INSURANCE Year:2019 | Volume:1 | Issue:4 Page(s): 153-158

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Information Journal Paper

Title

Discovering Self-referral between Doctors and Pharmacists Based on Network Mining

Author(s)

Askarzadeh Hassan | TAROKH MOHAMMAD JAFAR | Issue Writer Certificate

Keywords

Healthcare Insurance

Kickback

Self-Referral

Network Mining

Abstract

Introduction: A significant amount of treatment cost is paid by health insurance organization. Insurance companies mostly use reliable people to audit documents, but due to the very high number of documents and the limitation of time and human resource, it is almost impossible to consider documents carefully and more importantly, some infringements are not identifiable according to only one document, but identifiable by accumulation of documents and intelligent analysis based on data mining. Detection of beneficial referral (Self-Referral and Kickback) that a doctor refers a patient to a specific pharmacy that has benefits for him, is one of these things. Methods: In the current study, data pool was prepared using Tehran Health Insurance data until 2017 and then after eliminating faulty data, according to Network Mining methods, actions were taken to detect anomalistic referrals on the network, data filtering, and weighing the edges of the network based on the views of reliable people. This method was implemented in the Knime environment and a short list was presented to monitoring department of the health insurance organization. Results: In this research, according to the importance of detected interactions during Network Mining‘ s process between doctors and pharmacies, and using visual tools in Knime, 73 doctors were detected that had meaningful relation with 26 pharmacies. Conclusions: Inspectors of health insurance organization can have a more accurate and more effective examination with spending less time and human resource according to examination patterns based on Network Mining and visualization.

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APA: Copy

Askarzadeh, Hassan, & TAROKH, MOHAMMAD JAFAR. (2019). Discovering Self-referral between Doctors and Pharmacists Based on Network Mining. HEALTH INSURANCE, 1(4 ), 153-158. SID. https://sid.ir/paper/265939/en

Vancouver: Copy

Askarzadeh Hassan, TAROKH MOHAMMAD JAFAR. Discovering Self-referral between Doctors and Pharmacists Based on Network Mining. HEALTH INSURANCE[Internet]. 2019;1(4 ):153-158. Available from: https://sid.ir/paper/265939/en

IEEE: Copy

Hassan Askarzadeh, and MOHAMMAD JAFAR TAROKH, “Discovering Self-referral between Doctors and Pharmacists Based on Network Mining,” HEALTH INSURANCE, vol. 1, no. 4 , pp. 153–158, 2019, [Online]. Available: https://sid.ir/paper/265939/en

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