Vol. 23 No. Special Issue 3 (2024): Mapana - Journal of Sciences
Research Articles

The Need and Importance of Augmented AI/ML systems for Health Claims Fraud Detection

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  • Parul Naib,
  • Sudha Chandrashekar,
  • Shiv D Gupta
Parul Naib
IIHMR University
DOI: https://doi.org/10.12723/mjs.sp3.5

Published 2024-11-06

Keywords

  • fraud,
  • artificial intelligence,
  • machine learning,
  • health insurance,
  • claims,
  • healthcare fraud
    • ...More
    Less

Copyright (c) 2024

Creative Commons License

This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.

Abstract

Artificial Intelligence (AI) and Machine learning (ML) systems are increasingly being used to solve basic day-to-day problems. Chatbots such as Alexa and Siri play a big role in our day-to-day life with our reliance on these systems increasing by the day. The use of AI and ML systems is being increasingly explored, in fraud detection. particularly for the detection of fraud health insurance claims submitted by providers. Recently, several studies have leveraged AI/ML techniques to develop health claims fraud detection models with close to 100% accuracy rates. 

This paper looks at the limitations of the deep learning-based AI and ML models in the case of health claims fraud detection, and the associated challenges and implications. We then define an integrated AI/ML strategy augmented by human intelligence for  comprehensive fraud control to address the challenges and fraud detection using  AI/ML responsibly  without impacting the patient experience and health outcomes.

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