Using CommonKADS Method to Build Prototype System in Medical Insurance Fraud Detection

Abstract

At present, the false claim cases related to insurance fraud emerge endlessly. In respect of frequent fraud cases of social insurance undertaken by government organizations, the inspection procedure usually relies on experts’ experience for verification and experienced personnel in charge of checking. However, due to heavy work load insufficient manpower and lack of experience, the ratio of miscarriages of justice is very high, which leads to improper settlement of claims and the waste of social resources. In this paper, we used rule technology to improve the above inefficiency. We employ a knowledge engineering methodology to analyze problems and construct knowledge modesl, including the domain schema and rules. We implement the knowledge model along with the existing database applications. The benefits generated by the research are: (1) establishing a knowledge system with expertise reasoning to solve the review problems of massive cases, (2) significantly reducing the large labor cost and consumed time of the existing reviewing system, and (3) improving the application level of traditional database in the expert reasoning system.