Fraud Detection in Health Insurance Claims Based on Artificial Intelligence (AI)

Abstract

Fraud in health insurance claims has become a significant problem affecting the provision of healthcare globally. In addition to the financial losses incurred, patients who actually need medical treatment also suffer. This is because healthcare providers are not paid on time, as a result of delays in the manual scrutiny of their claims. Health insurance claim fraud is perpetrated through service providers, insurance customers, and insurance companies. The need for the development of a decision support system (DSS) for accurate claims processing that can automatically detect fraud is urgently needed. The purpose of this research is to create a machine learning model that can detect fraud in health insurance claims based on artificial intelligence (AI). The method used is Deep Learning. The accuracy obtained is an accuracy of 86%.