Accurate prediction of medical conditions with straight past clinical evidence is a long-sought topic in the medical management and health insurance field. Although great progress has been made with machine learning algorithms, the medical community is still skeptical about the model accuracy and interpretability. This paper presents an innovative hierarchical attention deep learning model to achieve better prediction and clear interpretability that can be easily understood by medical professionals. This paper developed an Interpretable Hierarchical Attention Network (IHAN). IHAN uses a hierarchical attention structure that matches naturally with the medical history data structure and reflects patients encounter (date of service) sequence. The model attention structure consists of 3 levels: (1) attention on the medical code types (diagnosis codes, procedure codes, lab test results, and prescription drugs), (2) attention on the sequential medical encounters within a type, (3) attention on the individual medical codes within an encounter and type. This model is applied to predict the occurrence of stage 3 chronic kidney disease (CKD), using three years medical history of Medicare Advantage (MA) members from an American nationwide health insurance company. The model takes members medical events, both claims and Electronic Medical Records (EMR) data, as input, makes a prediction of stage 3 CKD and calculates contribution from individual events to the predicted outcome.

A Clinical Decision Support System (CDSS) is designed to enhance clinician decision-making by combining system-generated recommendations with medical expertise. Given the high costs, intensive labor, and time-sensitive nature of medical treatments, there is a pressing need for efficient decision support, especially in complex emergency scenarios. In these scenarios, where information can be limited, an advanced CDSS framework that leverages AI (artificial intelligence) models to effectively reduce diagnostic uncertainty has utility. Such an AI-enabled CDSS framework with quantified uncertainty promises to be practical and beneficial in the demanding context of real-world medical care. In this study, we introduce the concept of Medical Entropy, quantifying uncertainties in patient outcomes predicted by neural machine translation based on the ICD-9 code of procedures. Our experimental results not only show strong correlations between procedure and diagnosis sequences based on the simple ICD-9 code but also demonstrate the promising capacity to model trends of uncertainties during hospitalizations through a data-driven approach.

The National Health Care Anti-Fraud Association (NHCAA) estimates that healthcare fraud costs the nation approximately $68 billion annually--3% of the nation's $2.26 trillion in healthcare spending. This is a conservative estimate; other estimates range as high as 10% of annual healthcare expenditure, or $230 billion. Healthcare fraud inevitably results in higher premiums and out-of-pocket expenses for consumers, as well as reduced benefits or coverage. Labeling a claim as fraudulent could require a complex and detailed investigation. This post demonstrates how to train an Amazon SageMaker model to flag anomalous post-payment Medicare inpatient claims and target them for further investigation on suspicion of fraud. The solution doesn't need labeled data; it uses unsupervised machine learning (ML) to create a model to flag suspicious claims. This solution uses Amazon SageMaker, which provides developer and data scientists with the ability to build, train, and deploy ML models.

Identifying patients who will be discharged within 24 hours can improve hospital resource management and quality of care. We studied this problem using eight years of Electronic Health Records (EHR) data from Stanford Hospital. We fit models to predict 24 hour discharge across the entire inpatient population. The best performing models achieved an area under the receiver-operator characteristic curve (AUROC) of 0.85 and an AUPRC of 0.53 on a held out test set. This model was also well calibrated. Finally, we analyzed the utility of this model in a decision theoretic framework to identify regions of ROC space in which using the model increases expected utility compared to the trivial always negative or always positive classifiers.

Insurance companies must manage millions of claims per year. While most of these claims are non-fraudulent, fraud detection is core for insurance companies. The ultimate goal is a predictive model to single out the fraudulent claims and pay out the non-fraudulent ones immediately. Modern machine learning methods are well suited for this kind of problem. Health care claims often have a data structure that is hierarchical and of variable length. We propose one model based on piecewise feed forward neural networks (deep learning) and another model based on self-attention neural networks for the task of claim management. We show that the proposed methods outperform bag-of-words based models, hand designed features, and models based on convolutional neural networks, on a data set of two million health care claims. The proposed self-attention method performs the best.

Nearly 250 years ago, the British East India Company under governor general Warren Hastings started'Dewani' (civil) and'Fauzdari' (criminal) court system. The first Law Commission, set up in 1834 under Lord T B Macaulay, did stupendous work towards codification of civil and criminal laws. After the Sepoy Mutiny in 1857, the British government acted on the drafts presented by the commission and enacted Civil Procedure Code, 1859; Indian Penal Code, 1860 and Criminal Procedure Code, 1861. Codification of civil and criminal laws led to a spurt in court-based litigation which stamped out the traditional panchayat system that provided inexpensive justice. By 1920s, India had a population of 11 crore. Yet, courts had started feeling the heat of pendency.

In order to submit a claim to insurance companies, a doctor needs to code a patient encounter with both the diagnosis (ICDs) and procedures performed (CPTs) in an Electronic Health Record (EHR). Identifying and applying relevant procedures code is a cumbersome and time-consuming task as a doctor has to choose from around 13,000 procedure codes with no predefined one-to-one mapping. In this paper, we propose a state-of-the-art deep learning method for automatic and intelligent coding of procedures (CPTs) from the diagnosis codes (ICDs) entered by the doctor. Precisely, we cast the learning problem as a multi-label classification problem and use distributed representation to learn the input mapping of high-dimensional sparse ICDs codes. Our final model trained on 2.3 million claims is able to outperform existing rule-based probabilistic and association-rule mining based methods and has a recall of 90@3.