Abstract:

The aim of this research is to develop a conceptual framework for health insurance companies to detect fraud committed by physicians by using data mining. The study revealed that most of the health insurance companies in Saudi Arabia are auditing claims manually, and they are in the process of automating such procedures.  This supports the idea of using data mining in detecting fraud. The paper concluded a recommendation to insurance companies to apply such a tool and to prepare a “black list” of physicians who are convicted in committing fraud.