Applications of Machine Learning in Medical Verification of Medical Insurance Claims
C Bhaskar Varma, Vinothkumar V,
Progress in Computing Applications, Vol. 13, No. 2, 2024.
DOI: https://doi.org/10.6025/pca/2024/13/2/59-66
Link: https://www.dline.info/pca/fulltext/v13n2/pcav13n2_1.pdf
Abstract:
In India, the high cost of medical education, particularly for an MBBS degree, poses significant challenges for new doctors, who often find that their qualifications do not justify the expenses incurred. This financial strain is exacerbated when these highly trained professionals are employed for routine tasks such as insurance treatment and billing verification, roles that are not commercially viable given their level of education and potential. As a cost-effective measure, many insurance companies and third-party administrators (TPAs) opt to employ doctors with BHMS or BAMS degrees for these tasks. However, these professionals are often underqualified for the complexities of medical verification, leading to inefficiencies and errors in treatment validation and anomaly detection. The situation also adversely affects government healthcare programs, where the need for accurate and efficient cashless medical services is critical. Delays and inaccuracies in medical verification can complicate the provision of timely healthcare to beneficiaries and their families, underscoring the need for improvement in these processes. This paper proposes the implementation of an Artificial Intelligence (AI) ecosystem designed to function as highly qualified medical agents. This AI system will be capable of independently verifying diagnoses, treatment plans, and medical reports for accuracy while identifying procedural anomalies. The primary objective is to augment the capabilities of the current workforce, enhancing overall efficiency and effectiveness in medical management. By deploying AI medical agents, the project aims to address the gap in qualification and task complexity and improve the accuracy and reliability of medical administrative processes. This initiative promises to revolutionise how medical verifications are handled, providing a sustainable, scalable solution to a pressing healthcare management issue in India.