Abstract: Systems and methods are provided for adaptive determination of healthcare claim integrity. The method can involve operating at least one processor to receive a healthcare claim request from a computing device; and apply initial healthcare claim request data to a claim integrity model to predict an initial integrity of the claim request.

Abstract: Aspects of the disclosed technology include a method including receiving, by a processor, first healthcare data including a first plurality of features of a plurality of candidate profiles; identifying, by the processor, a profile calculation window; creating, by the processor, a reference profile of the first healthcare data over the profile calculation window by dimensionally reducing the first plurality of features, the reference profile including a normal subspace and a residual subspace; analyzing, by the processor, the residual subspace of the reference profile; and detecting, based on the analyzed residual subspace, suspicious behavior of one or more first candidate profiles of the plurality of candidate profiles based on a deviation of the one or more first candidate profiles within the residual subspace from an expected profile.

Abstract: A method and system are provided for detecting fraudulent healthcare claim activity. An example system includes an analyzer to receive eligibility data related to an interaction between a service provider and a service recipient, and to generate one or more risk scores based on the eligibility data for a subsequent claim submitted based on the eligibility data, the eligibility data being accessed from at least one of a data stream and a storage component; a translator to interpret the one or more risk scores from the analyzer and to generate a user format representative of the one or more risk scores for the subsequent claim; and an interface component to cause a display of the user format.