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 textbooks Web site:

ch08_dentists.csv

ch08_claims.csv

ch08_patients.csv

Go to cengagebrain.com and search for this book by title or ISBN number. Then click Access

Now to download the data files. To ensure that the example data set does not inadvertently refer

to real dental offices or patients, each office and patient is referred to by ID rather than by name.

Questions

1. Some dental offices may not employ real dentists and may be front companies that are

sending claims out for work not performed. A real dental office should have a real office address

with dental chairs, reception areas, and so on. Are any dental offices instead of using post office

boxes in their payment addresses?

2. Real dentists should be sending claims to many different insurance companies. Since your

company only represents a few of these companies, the sequential numbers on the claim sheets

from a given dentist will rotate through all the companies that dentist is working with. If the

numbers sent to you from a given dentist are sequential, you know that the dentist is only

sending claims to you. Search the claims file for sequential numbers from any given dental office.

Are any sending you sequential claims?

3. 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 the three 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?

4. 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 customers address to

his or her dentists 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?