Shi, Yuliang (Shandong University) | Sun, Chenfei (Shandong University) | Li, Qingzhong (Shandong University) | Cui, Lizhen (Shandong University) | Yu, Han (Nanyang Technological University) | Miao, Chunyan (Nanyang Technological University)
As many countries in the world start to experience population aging, there are an increasing number of people relying on medical insurance to access healthcare resources. Medical insurance frauds are causing billions of dollars in losses for public healthcare funds. The detection of medical insurance frauds is an important and difficult challenge for the artificial intelligence (AI) research community. This paper outlines HFDA, a hybrid AI approach to effectively and efficiently identify fraudulent medical insurance claims which has been tested in an online medical insurance claim system in China.
In 2016 healthcare costs in the US are estimated at nearly 18% of the GDP! Healthcare is becoming less affordable worldwide and a serious chasm is widening between those that can afford healthcare and those that cannot. There are many factors driving the high cost of healthcare. One of them is fraud. In healthcare there are several types of fraud including prescription fraud, medical identity fraud, financial fraud, occupational fraud. The National Heath Care Anti-Fraud Association estimates conservatively that health care fraud costs the US about $68 billion annually -- about 3% the US nations total of $2.26 trillion in overall healthcare spending.
The National Healthcare Anti-Fraud Association estimates that health care fraud costs tens of billions of dollars every year. Health insurance special investigations units have long worked to stem the tide of losses, but it can be a challenge to stay ahead of the curve. To learn more about the tactics investigators employ and new tools at their disposal, SmartBrief spoke with Patrick Stamm, principal adviser to FraudScope, an AI-assisted platform for detecting health care fraud, waste and abuse. Please describe the existing health care FWA investigation paradigm and some ways in which it fails health plans? Historically, health care fraud investigations were almost exclusively initiated after the fact -- often as a result of a tip submitted to the special investigations unit from a member or employee who noticed something amiss while processing a claim.