From Prediction to Explainable Provider Behavior Profiles for Fraud, Waste, and Abuse Review

תקציר מקורי באנגליתarXiv:2609.28477v2 Announce Type: replace-cross Abstract: Claims data can show that provider behavior changed but cannot by itself explain why. Fraud, waste, and abuse (FWA) review requires identifying material behavior, locating the codes and dollars driving it, and testing plausible explanations. Forecast residuals conflate growth, service-line shifts, code maintenance, and incomplete observation with potentially concerning behavior. We instead formulate provider review as a descriptive representation problem: observed amount $y_{ijt}=s_{it}p_{ijt}$, where $s_{it}$ is provider scale and $p_{ijt}$ is procedure composition. The profile records scale history, effective-dated code lineage, clinical-family shares, first-use events, billing context, and Medicare-versus-client differences. An o