Towards protecting vital healthcare programs by extracting actionable knowledge from policy

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In challenging economic times, obtaining value for money by ensuring financial integrity and fairer distribution of services are among the top priorities for social and health-care systems globally. However, healthcare billing policies are complex and identifying non-compliance is often narrow-scope, manual and expensive. Maintaining ‘integrity’ is a challenge - ensuring that scarce resources get to those in need and are not lost to fraud and waste. Our approach fuses recent advances in dependency parsing with a policy ontology to convert the content of regulatory healthcare policy into human-friendly policy rules, that are amenable to machine-execution, with human oversight. We describe the ontology-guided transformation of textual patterns into a semantically-meaningful knowledge graph of rules, outline our experiments and evaluate results against policy rules obtained from professional investigators. The aim is to make a policy-compliance ‘landscape’ visible to healthcare programs - helping them identify Fraud, Waste or Abuse.