Case Study 2

You landed a summer internship with a company that processes dental insurance claims for insurance companies. The company receives the insurance claims from dental offices, achieves authorization from the correct insurance company, and sends payment checks. You do not deal with dental customers directly; instead, you work with insurance companies on one side and dental offices on the other.

After two months with the company, you think a number of frauds may be occurring, and you feel the best way to search for these frauds is to investigate documentary evidence. Because hundreds of dental offices send insurance claims to your office, some may not be real dental offices. You contact the IT department and receive a set of files that represent the documents involved in transactions for the past three months.

Download the following files from the textbook's Web site:

• ch08_dentists.csv
• ch08_claims.csv
• ch08_patients.csv

Questions

1. A human adult has 32 permanent teeth. Your company requires that each claim list the patient seen (identified by "patient id"), the tooth worked on, and the type of work done. Because of the natural limitation on the amount of cavities that could be filled on any one person, it is rare that a person would have more than a few cavities in thethree months of your audit (it is possible for a tooth to have more than one cavity). Using this field, calculate the total number of cavities submitted for each patient. Do any patients seem to be visiting the dentist too often?
2. Patients normally need to live close to their dentists because receiving service requires a visit to the office. A good fraud search is to calculate the distance from each customer's address to his or her dentist's office address using a geographic information system like Google Maps or MapQuest. For this question, simply determine if any patients live in different states than their dentists. Do any patients seem to have a long drive to their dentists' offices?