The task identifying changes and irregularities in medical insurance claim payments is a difficult process of which the traditional practice involves querying historical claims databases and flagging potential claims as normal or abnormal. Because what is considered as normal payment is usually unknown and may change over time, abnormal payments often pass undetected; only to be discovered when...

The objective of this study was to examine the relative efficacy of two different methodologies for auditing self-funded medical claim expenses: 100-percent-of-claims auditing versus random-sampling auditing. Multiple data sets of claim errors or 'exceptions' from two Fortune-100 corporations were analysed and compared to 100 simulated audits of 300- and 400-claim random samples. Random-sample ...

Although in literature few successful claims have been shown in comparison with other medical specialties such as gynaecology and orthopaedics, vascular surgery is included among high-risk specialties. The high-risk of receiving medical claims may lead vascular surgeons to practice defensive medicine, as is normal in several other areas of clinical practice. No studies are available to our know...

We study the behavior of rules for the adjudication of conflicting claims when there are a large number of claimants with small claims. We model such situations by replicating some basic problem. We show that under replication, the random arrival rule (O’Neill, 1982) behaves like the proportional rule, the rule that is the most often recommended in this context. Also, under replication, the min...

Consider the following nine rules for adjudicating conflicting claims: the proportional, constrained equal awards, constrained equal losses, Talmud, Piniles’, constrained egalitarian, adjusted proportional, random arrival, and minimal overlap rules. For each pair of rules in this list, we examine whether or not the two rules are Lorenz comparable. We allow the comparison to depend upon whether ...

A model of costly medical malpractice claims, based on Bayes Rule, is developed to examine the effects of physicians being liable for actual damage under a negligence rule. This model is consistent with empirical evidence concerning the pattern of claims. It is shown that compensating actual damage does not provide physicians with appropriate incentives to spend the second best optimal amount o...

The study of scepticism might be said to define epistemology. As the enquiry into the nature and sources of knowledge, epistemology's two fold concern is to identify and explicate the conditions whose satisfaction will amount to knowledge. Familiarly, one of these crucial conditions is justification. The problems facing the justification of knowledge-claims can best and most powerfully be descr...

We investigate the problem of verifying location claims of mobile devices, and propose a new property called simultaneous distance modification (SDM). In localization protocols satisfying the SDM property, a malicious device can lie about its distance from the verifiers, but all distances can only be altered by the same amount. We demonstrate that the SDM property guarantees secure verification...

Building reserves for outstanding liabilities is an important issue in the financial statement of any insurance company. In this paper we present a new model for delay in claim settlement and to predict IBNR (incurred but not reported) claims. The modelling is based on a data set of a portfolio of car liability data, which describes the claim settlement of a car insurance portfolio. The data co...