科研之友
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摘要
Medical insurance fraud is common in many countries' medical insurance systems and represents a serious threat to the insurance funds and the benefits of patients. In this paper, we present an inference model of medical insurance fraud detection, based on a medical detection domain ontology that incorporates the knowledge base provided by the Medical Terminology, NKIMed, and Chinese Library Classification systems. Through analyzing the behaviors of irregular and fraudulent medical services, we defined the scope of the medical domain ontology relevant to the task and built the ontology about medical sciences and medical service behaviors. The ontology then utilizes Semantic Web Rule Language (SWRL) and Java Expert System Shell (JESS) to detect medical irregularities and mine implicit knowledge. The system can be used to improve the management of medical insurance risks.
