Identifying fraud in medical insurance based on blockchain and deep learning

【Author】 Zhang, Guoming; Zhang, Xuyun; Bilal, Muhammad; Dou, Wanchun; Xu, Xiaolong; Rodrigues, Joel J. P. C.

【Source】FUTURE GENERATION COMPUTER SYSTEMS-THE INTERNATIONAL JOURNAL OF ESCIENCE

【影响因子】7.307

【Abstract】With the rapid growth of medical costs, the control of medical expenses has been becoming an important task of Health Insurance Department. Traditional medical insurance settlement is paid on a per-service basis, which leads to lots of unreasonable expenses. To cope with this problem, the single-disease payment mechanism has been widely used in recent years. However, the single-disease payment also has a risk of fraud. In this work, we propose a framework to identify fraud of medical insurance based on consortium blockchain and deep learning, which can recognize suspicious medical records automatically to ensure valid implementation on single-disease payment and lighten the work of medical insurance auditors. An explainable model BERT-LE is designed to evaluate the reasonability of ICD disease code for Medicare reimbursement by predicting the probability of a disease according to the chief complaint of a patient. We also put forward a storage and management process of medical records based on consortium blockchain to ensure the security, immutability, traceability, and auditability of the data. The experiments on two real datasets from two 3A hospitals demonstrate that the proposed solution can identify fraud effectively and greatly improve the efficiency in medical insurance reviews. (C) 2021 Elsevier B.V. All rights reserved.

【Keywords】Medical big data; Anti-fraud; Blockchain; Deep learning

【发表时间】2022 MAY

【收录时间】2022-07-10

【文献类型】理论性文章

【主题类别】

区块链应用-实体经济-医疗领域