AI Becoming an Invaluable Weapon in the Combat Against Health Insurance Fraud?

Health Insurance Fraud

Healthcare insurance has made patient care easily accessible to people from various categories, particularly the ones from rural and remote areas. While healthcare insurance is becoming an essential part of people’s lives, given the dramatic rise in health issues, it is also facing numerous sensitive issues, in terms of privacy, security, fraud, etc.

In the last couple of years, healthcare insurance fraud is becoming a concerning issue for insurance providers as it incurs high losses for private firms as well as individuals and the government. As published in a health insurance fraud article, 56% of life insurance providers stated a 30% increase in fraudulent activities over the last two years.

Studies also state that healthcare is one of the most vulnerable verticals of insurance claim fraud.

1. Types of health insurance fraud

Insurance fraud in healthcare occurs in numerous ways. But, it is challenging to list the various types of fraud because the nature of the deception keeps changing over time. However, some frauds keep happening more often. For instance:

Filing claims for service or treatment that were not delivered. This is often carried out by forging actual patient information and creating fake admissions

* Increasing overall hospital expenses by including treatments that were not necessary for the illness

* Adding treatments that were not a medical necessity

* Fabricating diagnosis reports to justify tests, surgeries, etc., and withholding information about pre-existing diseases to increase the credibility of claims

2. The increasing value of AI in preventing healthcare insurance fraud

Although insurance providers are taking preventive measures like

* Ensuring strict regulations and norms specific to specialty treatments and network hospitals

* Creating a centralized database to maintain a record of all fraudulent activities

* Rating healthcare service providers

* Assuring better due diligence in the underwriting process

And many more, they are still struggling to curb fraud in health insurance claims. Even the smallest of insurance fraud can turn extremely expensive for the provider. Hence, they have to analyze every claim meticulously before processing the claim settlement. Insurers typically read and verify hundreds of insurance claims every day, which is not only time-consuming but also increases the chances of missing out on fraud claims.

3. Applications of AI in the insurance industry

But with the help of modern-day technologies like AI, insurance providers have a better chance of reducing health insurance fraud. AI has numerous applications in the insurance industry. Some of them are:

3.1. Estimate the probability of claims

AI algorithms when trained appropriately on probability models can calculate the possibility of an incident happening by processing the available historical data. In addition, these algorithms can also calculate the value of the claim by evaluating similar claims raised by policyholders previously. Any claims beyond the threshold value can be red-flagged to SIU (Special Investigations Unit) for further investigation.

Health Insurance Claims

3.2. Detect patterns of insurance fraud

AI is one of the most glorified technologies of the era as it has the potential to swiftly identify patterns from massive datasets, which might take months or even years when done by humans, even if they are an expert in the field of analysis. 

Insurance providers can use AI models to quickly detect fraud activity patterns by identifying triggers such as repeated filing of claims, history of claim rejections, etc. Combining high-risk profiles with these parameters will help insurance providers prevent insurance fraud as well as closely monitor such policyholders in the future.

3.3. Generate evidence-based radiology reports

Radiology reports are paramount in insurance claims. Most insurance frauds occur by fabricating reports to support false health insurance claims. With the help of AI, insurance providers can check the credibility of radiology reports. For instance, in spine reporting, objective reports from quantitative imaging analysis can act as a concrete piece of evidence to verify insurance claims. 

With trained AI algorithms, insurance providers can create their own reports and cross-check them against the reports produced by the individual or the healthcare provider.

4. Conclusion

Artificial intelligence is growing smart every day. The technology overpowers other revolutionary technologies with its potential to mimic human intelligence. With the help of AI, insurance providers can not just detect and prevent fraud claims but also automate laborious tasks like document gathering and verification in insurance claim processes. This will enable insurers to work on other important tasks instead of screening documents. 

Timely and appropriate usage of technologies like AI will enable insurers to beat the detrimental effects of insurance fraud and reduce its occurrence. 

Synapsica, a leading AI health tech firm, is enabling insurance providers worldwide to prevent insurance fraud associated with spine problems. Our AI solutions, Spindle and SpindleX, can perform quantitative imaging analysis and generate objective reports instantaneously. This will help insurance providers quickly verify the credibility of the reports produced by individuals, clinics, or other health systems.

Are you an insurance provider looking to reduce health insurance fraud? Schedule a call with our product experts to check out how Spindle and SpindleX can aid your business.

AI Radiology | Synapsica

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