Title: A Social Network Analysis Framework for Modeling Health Insurance Claims Data,
Abstract: Health insurance companies in Brazil have their data about claims organized
having the view only for providers. In this way, they loose the physician view
and how they share patients. Partnership between physicians can view as a
fruitful work in most of the cases but sometimes this could be a problem for
health insurance companies and patients, for example a recommendation to visit
another physician only because they work in same clinic. The focus of the work
is to better understand physicians activities and how these activities are
represented in the data. Our approach considers three aspects: the
relationships among physicians, the relationships between physicians and
patients, and the relationships between physicians and health providers. We
present the results of an analysis of a claims database (detailing 18 months of
activity) from a large health insurance company in Brazil. The main
contribution presented in this paper is a set of models to represent: mutual
referral between physicians, patient retention, and physician centrality in the
health insurance network. Our results show the proposed models based on social
network frameworks, extracted surprising insights about physicians from real
health insurance claims data.