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February 25, 2021

Anti-Fraud Units, AI to Prevent Graft in Health Insurance Scheme | DataTrained

The health department has placed in place a system to identify fraudulent statements using artificial intelligence. Anti-fraud devices have been constituted to draw ahead suspected fraud filing of claims under the Ayushman Bharat-Mahatma Gandhi Rajasthan Swasthya Bima Yojana 2021-2023 re-launched by C.M. Ashok Gehlot last week.

Now, it won’t be easy for hospitals to encash fraud claims under this yojana.

The health department claimed which alleged incidents of filing of fraud assertions came directly to light in Bhamashah Swasthya Bima Yojna, which had been launched by the prior BJP government in 2015. The state government has brought the issues really that pointed out the involvement of corruption in the scheme. "Anti-fraud units will guarantee some kinds of filing of fraud claims," stated Gehlot, throughout the re-launching of AB-MGRSBY.

The state government is now taking the help of technologies for determining suspected fraudulent insurance claims refined by hospitals under AB-MGRSBY. Through artificial intelligence, the health department will analyze all claims booked under the scheme. Artificial intelligence will point out patterns that are not common. These cases will be scrutinized further through medical and data audits before being declared as fraud cases.

By making use of data available for filing claims by hospitals, artificial intelligence will immediately pick the uncommon pattern and indicate the anti-fraud unit to conduct scrutiny of the claims. If any hospital, which does not have facilities for cardiac surgery, and the hospital filed a claim for cardiac surgery, the use of artificial intelligence will immediately pick the odd filing of the claims.

The health department had found a hospital that was doing a particular surgery which was not happening in any other hospital in the numbers which it was doing. The hospital performed 96% of cases of that particular surgery, which drew suspicion.

After coming to power, Gehlot had guided the officials to take measures for protecting against such problems that had been allegedly claimed in the recently launched Ayushman Bharat Mahatma Gandhi Rajasthan Swasthya Bima Yojna (AB-MGRSBY).

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