Graphical Association Analysis for Identifying Variation in Provider Claims for Joint Replacement Surgery

Identifying potentially fraudulent or wasteful medical insurance claims can be difficult due to the large amounts of data and human effort involved. We applied unsupervised machine learning to construct interpretable models which rank variations in medical provider claiming behaviour in the domain of unilateral joint replacement surgery, using data from the Australian Medicare Benefits Schedule. For each of three surgical procedures reference models of claims for each procedure were constructed and compared analytically to models of individual provider claims. Providers were ranked using a score based on fees for typical claims made in addition to those in the reference model. Evaluation of the results indicated that the top-ranked providers were likely to be unusual in their claiming patterns, with typical claims from outlying providers adding up to 192% to the cost of a procedure. The method is efficient, generalizable to other procedures and, being interpretable, integrates well into existing workflows. © 2024 International Medical Informatics Association (IMIA) and IOS Press.