CleverCatch: A Knowledge-Guided Weak Supervision Model for Fraud Detection
It addresses fraud detection in healthcare, a high-stakes domain with limited labeled data, by combining expert rules with machine learning for better accuracy and interpretability, though it is incremental in its hybrid approach.
The paper tackles healthcare fraud detection by introducing CleverCatch, a knowledge-guided weak supervision model that integrates domain expertise into a neural architecture, resulting in improvements of 1.3% in AUC and 3.4% in recall over state-of-the-art baselines.
Healthcare fraud detection remains a critical challenge due to limited availability of labeled data, constantly evolving fraud tactics, and the high dimensionality of medical records. Traditional supervised methods are challenged by extreme label scarcity, while purely unsupervised approaches often fail to capture clinically meaningful anomalies. In this work, we introduce CleverCatch, a knowledge-guided weak supervision model designed to detect fraudulent prescription behaviors with improved accuracy and interpretability. Our approach integrates structured domain expertise into a neural architecture that aligns rules and data samples within a shared embedding space. By training encoders jointly on synthetic data representing both compliance and violation, CleverCatch learns soft rule embeddings that generalize to complex, real-world datasets. This hybrid design enables data-driven learning to be enhanced by domain-informed constraints, bridging the gap between expert heuristics and machine learning. Experiments on the large-scale real-world dataset demonstrate that CleverCatch outperforms four state-of-the-art anomaly detection baselines, yielding average improvements of 1.3\% in AUC and 3.4\% in recall. Our ablation study further highlights the complementary role of expert rules, confirming the adaptability of the framework. The results suggest that embedding expert rules into the learning process not only improves detection accuracy but also increases transparency, offering an interpretable approach for high-stakes domains such as healthcare fraud detection.