Fighting Against Organized Fraudsters Using Risk Diffusion-Based Parallel Graph Neural Network

Abstract

Medical insurance plays a vital role in modern society, yet organized healthcare fraud causes billions of dollars in annual losses, severely harming the sustainability of the social welfare system. Existing works mostly focus on detecting individual fraud entities or claims, ignoring hidden conspiracy patterns. Hence, they face severe challenges in tackling organized fraud. In this paper, we proposed RDPGL, a novel Risk Diffusion-based Parallel Graph Learning approach, to fighting against medical insurance criminal gangs. In particular, we first leverage a heterogeneous graph attention network to encode the local context from the beneficiary-provider graph. Then, we devise a community-aware risk diffusion model to infer the global context of organized fraud behaviors with the claim-claim relation graph. The local and global representations are parallel concatenated together and trained simultaneously in an end-to-end manner. Our approach is extensively evaluated on a real-world medical insurance dataset. The experimental results demonstrate the superiority of our proposed approach, which could detect more organized fraud claims with relatively high precision compared with state-of-the-art baselines.