{"id":"https://openalex.org/W3035773418","doi":"https://doi.org/10.3233/shti200287","title":"Ontology-Guided Policy Information Extraction for Healthcare Fraud Detection","display_name":"Ontology-Guided Policy Information Extraction for Healthcare Fraud Detection","publication_year":2020,"publication_date":"2020-01-01","ids":{"openalex":"https://openalex.org/W3035773418","doi":"https://doi.org/10.3233/shti200287","mag":"3035773418","pmid":"https://pubmed.ncbi.nlm.nih.gov/32570508"},"language":"en","primary_location":{"id":"doi:10.3233/shti200287","is_oa":true,"landing_page_url":"https://doi.org/10.3233/shti200287","pdf_url":null,"source":{"id":"https://openalex.org/S4210179765","display_name":"Studies in health technology and informatics","issn_l":"0926-9630","issn":["0926-9630","1879-8365"],"is_oa":false,"is_in_doaj":false,"is_core":true,"host_organization":"https://openalex.org/P4310318577","host_organization_name":"IOS Press","host_organization_lineage":["https://openalex.org/P4310318577"],"host_organization_lineage_names":["IOS Press"],"type":"book series"},"license":"cc-by-nc","license_id":"https://openalex.org/licenses/cc-by-nc","version":"publishedVersion","is_accepted":true,"is_published":true,"raw_source_name":"Studies in Health Technology and Informatics","raw_type":"book-chapter"},"type":"book-chapter","indexed_in":["crossref","pubmed"],"open_access":{"is_oa":true,"oa_status":"hybrid","oa_url":"https://doi.org/10.3233/shti200287","any_repository_has_fulltext":false},"authorships":[{"author_position":"first","author":{"id":"https://openalex.org/A5071741898","display_name":"Theodora S. Brisimi","orcid":"https://orcid.org/0000-0002-0985-6433"},"institutions":[{"id":"https://openalex.org/I4210145784","display_name":"IBM Research - Ireland","ror":"https://ror.org/04jnxr720","country_code":"IE","type":"facility","lineage":["https://openalex.org/I1341412227","https://openalex.org/I4210114115","https://openalex.org/I4210145784"]}],"countries":["IE"],"is_corresponding":false,"raw_author_name":"Brisimi Theodora S.","raw_affiliation_strings":["IBM Research, Ireland"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"IBM Research, Ireland","institution_ids":["https://openalex.org/I4210145784"]}]},{"author_position":"middle","author":{"id":"https://openalex.org/A5030268064","display_name":"Vanessa L\u00f3pez","orcid":"https://orcid.org/0000-0002-0674-5324"},"institutions":[{"id":"https://openalex.org/I4210145784","display_name":"IBM Research - Ireland","ror":"https://ror.org/04jnxr720","country_code":"IE","type":"facility","lineage":["https://openalex.org/I1341412227","https://openalex.org/I4210114115","https://openalex.org/I4210145784"]}],"countries":["IE"],"is_corresponding":false,"raw_author_name":"Lopez Vanessa","raw_affiliation_strings":["IBM Research, Ireland"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"IBM Research, Ireland","institution_ids":["https://openalex.org/I4210145784"]}]},{"author_position":"middle","author":{"id":"https://openalex.org/A5069190610","display_name":"Valentina Rho","orcid":null},"institutions":[{"id":"https://openalex.org/I4210145784","display_name":"IBM Research - Ireland","ror":"https://ror.org/04jnxr720","country_code":"IE","type":"facility","lineage":["https://openalex.org/I1341412227","https://openalex.org/I4210114115","https://openalex.org/I4210145784"]}],"countries":["IE"],"is_corresponding":false,"raw_author_name":"Rho Valentina","raw_affiliation_strings":["IBM Research, Ireland"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"IBM Research, Ireland","institution_ids":["https://openalex.org/I4210145784"]}]},{"author_position":"middle","author":{"id":"https://openalex.org/A5047333523","display_name":"Marco Luca Sbodio","orcid":"https://orcid.org/0009-0002-5255-7698"},"institutions":[{"id":"https://openalex.org/I4210145784","display_name":"IBM Research - Ireland","ror":"https://ror.org/04jnxr720","country_code":"IE","type":"facility","lineage":["https://openalex.org/I1341412227","https://openalex.org/I4210114115","https://openalex.org/I4210145784"]}],"countries":["IE"],"is_corresponding":false,"raw_author_name":"Sbodio Marco","raw_affiliation_strings":["IBM Research, Ireland"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"IBM Research, Ireland","institution_ids":["https://openalex.org/I4210145784"]}]},{"author_position":"middle","author":{"id":"https://openalex.org/A5033069481","display_name":"Gabriele Picco","orcid":null},"institutions":[{"id":"https://openalex.org/I4210145784","display_name":"IBM Research - Ireland","ror":"https://ror.org/04jnxr720","country_code":"IE","type":"facility","lineage":["https://openalex.org/I1341412227","https://openalex.org/I4210114115","https://openalex.org/I4210145784"]}],"countries":["IE"],"is_corresponding":false,"raw_author_name":"Picco Gabriele","raw_affiliation_strings":["IBM Research, Ireland"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"IBM Research, Ireland","institution_ids":["https://openalex.org/I4210145784"]}]},{"author_position":"middle","author":{"id":"https://openalex.org/A5067775199","display_name":"Morten Kristiansen","orcid":"https://orcid.org/0000-0001-9652-3348"},"institutions":[{"id":"https://openalex.org/I1341412227","display_name":"IBM (United States)","ror":"https://ror.org/05hh8d621","country_code":"US","type":"company","lineage":["https://openalex.org/I1341412227"]}],"countries":["US"],"is_corresponding":false,"raw_author_name":"Kristiansen Morten","raw_affiliation_strings":["IBM Watson Health, GHHS, Ireland"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"IBM Watson Health, GHHS, Ireland","institution_ids":["https://openalex.org/I1341412227"]}]},{"author_position":"middle","author":{"id":"https://openalex.org/A5010834446","display_name":"John Segrave-Daly","orcid":"https://orcid.org/0000-0003-2172-1870"},"institutions":[{"id":"https://openalex.org/I1341412227","display_name":"IBM (United States)","ror":"https://ror.org/05hh8d621","country_code":"US","type":"company","lineage":["https://openalex.org/I1341412227"]}],"countries":["US"],"is_corresponding":false,"raw_author_name":"Segrave-Daly John","raw_affiliation_strings":["IBM Watson Health, GHHS, Ireland"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"IBM Watson Health, GHHS, Ireland","institution_ids":["https://openalex.org/I1341412227"]}]},{"author_position":"last","author":{"id":"https://openalex.org/A5047354986","display_name":"Conor P. Cullen","orcid":null},"institutions":[{"id":"https://openalex.org/I1341412227","display_name":"IBM (United States)","ror":"https://ror.org/05hh8d621","country_code":"US","type":"company","lineage":["https://openalex.org/I1341412227"]}],"countries":["US"],"is_corresponding":false,"raw_author_name":"Cullen Conor","raw_affiliation_strings":["IBM Watson Health, GHHS, Ireland"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"IBM Watson Health, GHHS, Ireland","institution_ids":["https://openalex.org/I1341412227"]}]}],"institutions":[],"countries_distinct_count":2,"institutions_distinct_count":2,"corresponding_author_ids":[],"corresponding_institution_ids":[],"apc_list":null,"apc_paid":null,"fwci":0.5272,"has_fulltext":false,"cited_by_count":4,"citation_normalized_percentile":{"value":0.69601159,"is_in_top_1_percent":false,"is_in_top_10_percent":false},"cited_by_percentile_year":{"min":89,"max":97},"biblio":{"volume":"270","issue":null,"first_page":"879","last_page":"883"},"is_retracted":false,"is_paratext":false,"is_xpac":false,"primary_topic":{"id":"https://openalex.org/T11652","display_name":"Imbalanced Data Classification Techniques","score":0.8446999788284302,"subfield":{"id":"https://openalex.org/subfields/1702","display_name":"Artificial Intelligence"},"field":{"id":"https://openalex.org/fields/17","display_name":"Computer Science"},"domain":{"id":"https://openalex.org/domains/3","display_name":"Physical Sciences"}},"topics":[{"id":"https://openalex.org/T11652","display_name":"Imbalanced Data Classification Techniques","score":0.8446999788284302,"subfield":{"id":"https://openalex.org/subfields/1702","display_name":"Artificial Intelligence"},"field":{"id":"https://openalex.org/fields/17","display_name":"Computer Science"},"domain":{"id":"https://openalex.org/domains/3","display_name":"Physical Sciences"}}],"keywords":[{"id":"https://openalex.org/keywords/medicaid","display_name":"Medicaid","score":0.739245593547821},{"id":"https://openalex.org/keywords/payment","display_name":"Payment","score":0.6152528524398804},{"id":"https://openalex.org/keywords/audit","display_name":"Audit","score":0.561734676361084},{"id":"https://openalex.org/keywords/reimbursement","display_name":"Reimbursement","score":0.5580403208732605},{"id":"https://openalex.org/keywords/consistency","display_name":"Consistency (knowledge bases)","score":0.5374420881271362},{"id":"https://openalex.org/keywords/mandate","display_name":"Mandate","score":0.5331795811653137},{"id":"https://openalex.org/keywords/adjudication","display_name":"Adjudication","score":0.5014567375183105},{"id":"https://openalex.org/keywords/health-care","display_name":"Health care","score":0.5007107257843018},{"id":"https://openalex.org/keywords/ontology","display_name":"Ontology","score":0.46592140197753906},{"id":"https://openalex.org/keywords/business","display_name":"Business","score":0.45208919048309326},{"id":"https://openalex.org/keywords/deliberation","display_name":"Deliberation","score":0.45140066742897034},{"id":"https://openalex.org/keywords/computer-science","display_name":"Computer science","score":0.43395617604255676},{"id":"https://openalex.org/keywords/actuarial-science","display_name":"Actuarial science","score":0.33469289541244507},{"id":"https://openalex.org/keywords/accounting","display_name":"Accounting","score":0.17917317152023315},{"id":"https://openalex.org/keywords/finance","display_name":"Finance","score":0.16953739523887634},{"id":"https://openalex.org/keywords/artificial-intelligence","display_name":"Artificial intelligence","score":0.11911118030548096},{"id":"https://openalex.org/keywords/political-science","display_name":"Political science","score":0.09442654252052307}],"concepts":[{"id":"https://openalex.org/C2776534028","wikidata":"https://www.wikidata.org/wiki/Q1141363","display_name":"Medicaid","level":3,"score":0.739245593547821},{"id":"https://openalex.org/C145097563","wikidata":"https://www.wikidata.org/wiki/Q1148747","display_name":"Payment","level":2,"score":0.6152528524398804},{"id":"https://openalex.org/C199521495","wikidata":"https://www.wikidata.org/wiki/Q181487","display_name":"Audit","level":2,"score":0.561734676361084},{"id":"https://openalex.org/C2779703844","wikidata":"https://www.wikidata.org/wiki/Q760125","display_name":"Reimbursement","level":3,"score":0.5580403208732605},{"id":"https://openalex.org/C2776436953","wikidata":"https://www.wikidata.org/wiki/Q5163215","display_name":"Consistency (knowledge bases)","level":2,"score":0.5374420881271362},{"id":"https://openalex.org/C2775884135","wikidata":"https://www.wikidata.org/wiki/Q845436","display_name":"Mandate","level":2,"score":0.5331795811653137},{"id":"https://openalex.org/C204434341","wikidata":"https://www.wikidata.org/wiki/Q357789","display_name":"Adjudication","level":2,"score":0.5014567375183105},{"id":"https://openalex.org/C160735492","wikidata":"https://www.wikidata.org/wiki/Q31207","display_name":"Health care","level":2,"score":0.5007107257843018},{"id":"https://openalex.org/C25810664","wikidata":"https://www.wikidata.org/wiki/Q44325","display_name":"Ontology","level":2,"score":0.46592140197753906},{"id":"https://openalex.org/C144133560","wikidata":"https://www.wikidata.org/wiki/Q4830453","display_name":"Business","level":0,"score":0.45208919048309326},{"id":"https://openalex.org/C2776946740","wikidata":"https://www.wikidata.org/wiki/Q358652","display_name":"Deliberation","level":3,"score":0.45140066742897034},{"id":"https://openalex.org/C41008148","wikidata":"https://www.wikidata.org/wiki/Q21198","display_name":"Computer science","level":0,"score":0.43395617604255676},{"id":"https://openalex.org/C162118730","wikidata":"https://www.wikidata.org/wiki/Q1128453","display_name":"Actuarial science","level":1,"score":0.33469289541244507},{"id":"https://openalex.org/C121955636","wikidata":"https://www.wikidata.org/wiki/Q4116214","display_name":"Accounting","level":1,"score":0.17917317152023315},{"id":"https://openalex.org/C10138342","wikidata":"https://www.wikidata.org/wiki/Q43015","display_name":"Finance","level":1,"score":0.16953739523887634},{"id":"https://openalex.org/C154945302","wikidata":"https://www.wikidata.org/wiki/Q11660","display_name":"Artificial intelligence","level":1,"score":0.11911118030548096},{"id":"https://openalex.org/C17744445","wikidata":"https://www.wikidata.org/wiki/Q36442","display_name":"Political science","level":0,"score":0.09442654252052307},{"id":"https://openalex.org/C199539241","wikidata":"https://www.wikidata.org/wiki/Q7748","display_name":"Law","level":1,"score":0.0},{"id":"https://openalex.org/C94625758","wikidata":"https://www.wikidata.org/wiki/Q7163","display_name":"Politics","level":2,"score":0.0},{"id":"https://openalex.org/C138885662","wikidata":"https://www.wikidata.org/wiki/Q5891","display_name":"Philosophy","level":0,"score":0.0},{"id":"https://openalex.org/C111472728","wikidata":"https://www.wikidata.org/wiki/Q9471","display_name":"Epistemology","level":1,"score":0.0}],"mesh":[{"descriptor_ui":"D005607","descriptor_name":"Fraud","qualifier_ui":null,"qualifier_name":null,"is_major_topic":true},{"descriptor_ui":"D005607","descriptor_name":"Fraud","qualifier_ui":null,"qualifier_name":null,"is_major_topic":true},{"descriptor_ui":"D005607","descriptor_name":"Fraud","qualifier_ui":null,"qualifier_name":null,"is_major_topic":true},{"descriptor_ui":"D006278","descriptor_name":"Medicare","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D006278","descriptor_name":"Medicare","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D006278","descriptor_name":"Medicare","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D006801","descriptor_name":"Humans","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D006801","descriptor_name":"Humans","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D006801","descriptor_name":"Humans","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D008484","descriptor_name":"Medicaid","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D008484","descriptor_name":"Medicaid","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D008484","descriptor_name":"Medicaid","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D014481","descriptor_name":"United States","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D014481","descriptor_name":"United States","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D014481","descriptor_name":"United States","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D016247","descriptor_name":"Information Storage and Retrieval","qualifier_ui":null,"qualifier_name":null,"is_major_topic":true},{"descriptor_ui":"D016247","descriptor_name":"Information Storage and Retrieval","qualifier_ui":null,"qualifier_name":null,"is_major_topic":true},{"descriptor_ui":"D016247","descriptor_name":"Information Storage and Retrieval","qualifier_ui":null,"qualifier_name":null,"is_major_topic":true},{"descriptor_ui":"D057766","descriptor_name":"Policy","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D057766","descriptor_name":"Policy","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D057766","descriptor_name":"Policy","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false}],"locations_count":2,"locations":[{"id":"doi:10.3233/shti200287","is_oa":true,"landing_page_url":"https://doi.org/10.3233/shti200287","pdf_url":null,"source":{"id":"https://openalex.org/S4210179765","display_name":"Studies in health technology and informatics","issn_l":"0926-9630","issn":["0926-9630","1879-8365"],"is_oa":false,"is_in_doaj":false,"is_core":true,"host_organization":"https://openalex.org/P4310318577","host_organization_name":"IOS Press","host_organization_lineage":["https://openalex.org/P4310318577"],"host_organization_lineage_names":["IOS Press"],"type":"book series"},"license":"cc-by-nc","license_id":"https://openalex.org/licenses/cc-by-nc","version":"publishedVersion","is_accepted":true,"is_published":true,"raw_source_name":"Studies in Health Technology and Informatics","raw_type":"book-chapter"},{"id":"pmid:32570508","is_oa":false,"landing_page_url":"https://pubmed.ncbi.nlm.nih.gov/32570508","pdf_url":null,"source":{"id":"https://openalex.org/S4306525036","display_name":"PubMed","issn_l":null,"issn":null,"is_oa":false,"is_in_doaj":false,"is_core":false,"host_organization":"https://openalex.org/I1299303238","host_organization_name":"National Institutes of Health","host_organization_lineage":["https://openalex.org/I1299303238"],"host_organization_lineage_names":[],"type":"repository"},"license":null,"license_id":null,"version":"publishedVersion","is_accepted":true,"is_published":true,"raw_source_name":"Studies in health technology and informatics","raw_type":null}],"best_oa_location":{"id":"doi:10.3233/shti200287","is_oa":true,"landing_page_url":"https://doi.org/10.3233/shti200287","pdf_url":null,"source":{"id":"https://openalex.org/S4210179765","display_name":"Studies in health technology and informatics","issn_l":"0926-9630","issn":["0926-9630","1879-8365"],"is_oa":false,"is_in_doaj":false,"is_core":true,"host_organization":"https://openalex.org/P4310318577","host_organization_name":"IOS Press","host_organization_lineage":["https://openalex.org/P4310318577"],"host_organization_lineage_names":["IOS Press"],"type":"book series"},"license":"cc-by-nc","license_id":"https://openalex.org/licenses/cc-by-nc","version":"publishedVersion","is_accepted":true,"is_published":true,"raw_source_name":"Studies in Health Technology and Informatics","raw_type":"book-chapter"},"sustainable_development_goals":[{"display_name":"Peace, Justice and strong institutions","score":0.800000011920929,"id":"https://metadata.un.org/sdg/16"}],"awards":[],"funders":[],"has_content":{"pdf":false,"grobid_xml":false},"content_urls":null,"referenced_works_count":0,"referenced_works":[],"related_works":["https://openalex.org/W2884884929","https://openalex.org/W4405446461","https://openalex.org/W2099446961","https://openalex.org/W4392801224","https://openalex.org/W2477464958","https://openalex.org/W88823410","https://openalex.org/W2186009000","https://openalex.org/W2415225706","https://openalex.org/W2103424770","https://openalex.org/W4283367253"],"abstract_inverted_index":{"Financial":[0],"losses":[1],"in":[2,10,18,29,54,124,160,167,184],"Medicaid,":[3],"from":[4,139],"Fraud,":[5],"Waste":[6],"and":[7,60,104,122,165,172,181],"Abuse":[8],"(FWA),":[9],"the":[11,19,36,62,66,135,153,168],"United":[12],"States":[13],"are":[14],"estimated":[15],"to":[16,39,64,85,90,106,118,162,174,182],"be":[17,112],"tens":[20],"of":[21,23,42,68,116,170],"billions":[22],"dollars":[24],"each":[25],"year.":[26],"This":[27],"results":[28],"escalating":[30],"costs":[31],"as":[32,34],"well":[33],"limiting":[35],"funding":[37],"available":[38],"worthy":[40],"recipients":[41],"healthcare.":[43],"The":[44],"Centers":[45],"for":[46,73],"Medicare":[47],"&":[48],"Medicaid":[49],"Services":[50],"mandate":[51],"thorough":[52],"auditing,":[53],"which":[55],"policy":[56,63,88,127],"investigators":[57,159],"manually":[58],"research":[59],"interpret":[61,86],"validate":[65,134],"integrity":[67],"claims":[69,117,129,171],"submitted":[70],"by":[71,96,146],"providers":[72,176],"reimbursement,":[74],"a":[75,81,97],"very":[76],"time-consuming":[77],"process.":[78],"We":[79,133],"propose":[80],"system":[82,101,131,154],"that":[83,110,177],"aims":[84],"unstructured":[87],"text":[89],"semi-automatically":[91],"audit":[92],"provider":[93],"claims.":[94],"Guided":[95],"domain":[98,147],"ontology,":[99],"our":[100],"extracts":[102],"entities":[103],"relations":[105],"build":[107],"benefit":[108],"rules":[109],"can":[111,155],"executed":[113],"on":[114,142],"top":[115],"identify":[119,175],"improper":[120],"payments,":[121],"often":[123],"turn":[125],"payment":[126],"or":[128],"adjudication":[130],"vulnerabilities.":[132],"automatic":[136],"knowledge":[137],"extraction":[138],"policies":[140,180],"based":[141],"ground":[143],"truth":[144],"created":[145],"experts.":[148],"Lastly,":[149],"we":[150],"discuss":[151],"how":[152],"co-reason":[156],"with":[157],"human":[158],"order":[161],"increase":[163],"thoroughness":[164],"consistency":[166],"review":[169],"policy,":[173],"systematically":[178],"violate":[179],"help":[183],"prioritising":[185],"investigations.":[186]},"counts_by_year":[{"year":2026,"cited_by_count":1},{"year":2025,"cited_by_count":1},{"year":2024,"cited_by_count":1},{"year":2022,"cited_by_count":1}],"updated_date":"2026-07-31T08:31:51.225901","created_date":"2025-10-10T00:00:00"}