AI and Blockchain empowered Health Insurance Fraud Detection

Abstract

Nowadays, health insurance is becoming an important part of people's lives, as the increase in the number of health issues. Healthcare emergencies can be troublesome for the people who can't afford the huge expenses. Health insurance helps people to cover expensive healthcare services in case of a medical emergency and provides financial protection against indebtedness risk. Health insurance along with its several benefits can face many security, privacy, and fraud issues. From the past few years, fraud has been a sensitive issue in the health insurance domain. Health insurance fraud incurs high loss for individuals, private firms, and governments. So, it is essential for national authorities and private firms to develop systems for detecting the fraudulent cases and payments. A high volume of health insurance data in electronic form is generated. This data is highly sensitive, and attracts hackers for cyber-attacks. Motivated by these facts, in this research project, we introduce a AI and blockchain-enabled secure health insurance fraud detection system. This project introduces the security issue of health insurance. We proposed an intelligent architecture for health insurance fraud detection and a case study using machine learning and blockchain. We build ML model to predict a healthcare service provider is potentially fraudulent or not to prevent the financial loss. The model build using bagging classifier is able to successfully predict potentially fraudulent classes of healthcare service provider with an F1-score over 0.95. Furthermore, we develop smart contract based on HIC fraud detection system on blockchain technology to validate the transaction of HIC. The proposed smart contract deployed on the Remix Ethereum to protects transaction history to enhance security and HIC data privacy. Finally, the open issues and research challenges of blockchain and an AI-empowered health insurance fraud detection system are collated.