Leveraging evolutionary algorithms with a dynamic weighted search space approach for fraud detection in healthcare insurance claims

• Published in: Knowledge-based systems Vol. 317; p. 113436
• Main Authors: Tubishat, Mohammad, Tbaishat, Dina, Al-Zoubi, Ala’ M., Hraiz, Abed-Elalim, Habib, Maria
• Format: Journal Article
• Language: English
• Published: Elsevier B.V 23.05.2025
• Subjects: Claims; Detection; Dynamic search space; Feature weighing; LLM; Medical fraud; Optimization algorithms; SVM; Claims; Feature weighing; Optimization algorithms; Medical fraud; Dynamic search space; SVM; Detection; LLM
• ISSN: 0950-7051
• DOI: 10.1016/j.knosys.2025.113436

The healthcare industry has been suffering from fraud in many facets for decades, resulting in millions of dollars lost to fictitious claims at the expense of other patients who cannot afford appropriate care. As such, accurately identifying fraudulent claims is one of the most important factors in a well-functioning healthcare system. However, over time, fraud has become harder to detect because of increasingly complex and sophisticated fraud scheme development, data unpreparedness, as well as data privacy concerns. Moreover, traditional methods are proving increasingly inadequate in addressing this issue. To solve this issue a novel evolutionary dynamic weighted search space approach (DW-WOA-SVM) is presented in the current study. The approach has different levels that work simultaneously, where the optimization algorithm is responsible for tuning the Support Vector Machine (SVM) parameters, applying the weighting procedure for the features, and using a dynamic search space to adjust the range values. Tuning the parameters benefits the performance of SVM, and the weighting technique makes it updated with importance and lets the algorithm focus on data structure in addition to optimization objectives. The dynamic search space enhances the search range during the process. Furthermore, large language models have been applied to generate the dataset to improve the quality of the data and address the lack of good dimensionality, helping to enhance the richness of the data. The experiments highlighted the superior performance of this proposed approach than other algorithms.