A decision support tool for identifying abuse of controlled substances by forwardhealth medicaid members

Journal of Hospital Marketing and Public Relations

Volumn 20, Issue 1, 2010, Pages 34-55

  Mailloux, Allan T ^a   Cummings, Stephen W ^a   Mugdh, Mrinal ^b  

^a APS Healthcare   (United States)

^b UNIVERSITY OF HOUSTON   (United States)

Author keywords

Controlled substances; Decision tree; Drug abuse; Fraud and abuse; Medicaid

Indexed keywords

FENTANYL; HYDROCODONE; MORPHINE SULFATE; OXYCODONE; TRAMADOL;

ALGORITHM; ARTICLE; AUTOMATION; CHI SQUARE TEST; CLASSIFICATION; CLINICAL ASSESSMENT; DECISION SUPPORT SYSTEM; DRUG ABUSE; DRUG MISUSE; DRUG UTILIZATION; HEALTH CARE; HEALTH CARE COST; HEALTH INSURANCE; HOSPITAL DEPARTMENT; HUMAN; MEDICAID; MEDICAL SERVICE; PHARMACIST; PHARMACY; PRACTICE GUIDELINE; PREDICTIVE VALIDITY; PRESCRIPTION; PRIORITY JOURNAL; PROFESSIONAL PRACTICE; SCORING SYSTEM; STANDARD; SUBSTANCE ABUSE;

CHI-SQUARE DISTRIBUTION; DECISION TREES; FRAUD; HUMANS; MEDICAID; PHARMACEUTICAL PREPARATIONS; SUBSTANCE-RELATED DISORDERS; UNITED STATES; WISCONSIN;

EID: 75649102422     PISSN: 15390942     EISSN: 15390934     Source Type: Journal    
DOI: 10.1080/15390940903450982     Document Type: Article

References (19)

1. Health care fraud: A serious and costly reality for all Americans. Retrieved November 3, 2004, from National Health Care Anti-Fraud Association Web site: http://www.nhcaa.org/pdf/all about hcf.pdf
2. Health care fraud: Information-sharing proposals to improve enforcement efforts. (1996, May). GAO report to the banking minority member, subcommittee on National Security, International Affairs and Criminal Justice. Retrieved November 3, 2004, from House Committee on Government Reform and Oversight, Security Management Web site: http://securitymanagement.com/library/000187 html
3. GAO strategic plan, performance, and accountability 2004-2009, Strategic area supplement for strategic plan, strategic objective 1.1: The health needs of an aging and diverse population. Retrieved November 3, 2004, from Government Accountability Office Web site: http://www.gao.gov/sp/d0453sp.pdf
4. US Department of Health and Human Services and the Department of Justice (2002, April). Health care fraud and abuse control program annual report for FY 2001. Retrieved November 3, 2004, from the US Department of Justice and the Office of the Deputy Attorney General Web sites: http://www. usdoj.gov/dag/pubdoc/hipaa01fe19.htm
5. US Department of Justice. (2004, August). Oxycontin diversion, availability, and abuse. Retrieved November 4, 2004, US Department of Justice, National Drug Intelligence Center Web site: http://www.usdoj.gov/ndic/pubs10/ 10550/ 10550p.pdf
6. Code of Federal Regulations, Title 42 Public Health, Part 456-Utilization Control, Subpart K. Drug use review program and electronic claims management system for outpatient drug claims. Retrieved November 1, 2004, from http://www.washingtonwatchdog.org/documents/cfr/title42/part456.html
7. Centers for Medicare and Medicaid Services. (2001, October). National Medicaid fraud and abuse initiative's information systems workgroup. Resource guide of state fraud and abuse systems. Retrieved July 31, 2003, from Centers for Medicare and Medicaid Services Web site: http://cms.hhs.gov/states/fraud/ systmgde.pdf
8. Centers for Medicare and Medicaid Services. National fraud and abuse team and the Center for Medicaid and state operations. Guidance and best practices relating to the states' surveillance and utilization review functions. Retrieved July 31, 2003, from Centers for Medicare and Medicaid Services Web site: http://cms.gov/states/fraud/surutil.pdf
9. Thompson W. (1999). Using DSS technology to transform the way Wisconsin Medicaid does business. Data Warehousing: What Works? 8, 2-3.
10. Steele B. Reshaping the data landscape. Retrieved September 22, 2003, from EDS Corporation Web site: http://www.eds.com/health care/medicaid/images/WP ReshapDataLandscape.pdf
11. Berry M., & Linoff, G. (2000). Mastering Data Mining. John Wiley & Sons.
12. SPSS White Paper. Data mining: An introduction. Retrieved November 7, 2004, from SPSS Web site: http://hqftp1.spss.com/pub/web/wp/WPDMINTRO-0699.pdf
13. Berson, A., Smith, S., & Thearling, K. An overview of data mining techniques, excerpted from Building Data Mining Applications for CRM. Retrieved October 28, 2004, from Kurt Thearling Web site: http://www.thearling.com/text/ dmtechniques/ dmtechniques.htm
14. Lay, R. S., & Maguire, J. J. (1983, Fall). Computer aided segmentation analysis: New software for college admissions marketing. Journal of College Admissions, 32-36.
15. Borden, V. M. H. (1995). Segmenting student markets with a student satisfaction and priorities survey. Research in Higher Education, 36(1), 73-88.
16. Grampian visitor survey market segmentation analysis. (2000, July). Retrieved August 13, 2003, from Scottish Enterprise Web site: http://www.scottishenterprise. com/publications/gvs market segment analysis.pdf
17. SPSS R AnswerTree [computer program]. (2002). Version 3.0. Chicago, IL: SPSS Inc.
18. Mailloux, A. T., Mergener, M. A., Carr, R. M., & Howe, M. J. (1999, December). Cost benefit analysis of the Wisconsin Medicaid recipient lock-in program. Paper (poster) presented at the 1999 American Society Health-Systems Pharmacist Midyear Clinical Meeting on December 6, 1999, Orlando, FL.
19. Valenstein, M., Copeland, L. A., Blow, F. C., et al. (2002). Pharmacy data identify poorly adherent patients with schizophrenia at increased risk for admission. Med Care, 40, 630-639.