Study Data from Nanjing University Update Understanding of Managed Care (Identifying Fraud In Medical Insurance Based On Blockchain and Deep Learning): Managed Care

2022 AUG 03 (NewsRx) -- By a News Reporter-Staff News Editor at Health Policy and Law Daily -- Current study results on Managed Care have been published. According to news reporting from Nanjing, People’s Republic of China, by NewsRx journalists, research stated, “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.”

Funders for this research include National Key R&D Program of China, National Natural Science Foundation of China (NSFC), Jiangsu Key R&D Program of China, Collaborative Innovation Center of Novel Software Technology and Industrialization, Nanjing University, European Commission, European Commission, Conselho Nacional de Desenvolvimento Cientifico e Tecnologico (CNPQ).

The news correspondents obtained a quote from the research from Nanjing University, “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.”

According to the news reporters, the research concluded: “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.”

This research has been peer-reviewed.

For more information on this research see: Identifying Fraud In Medical Insurance Based On Blockchain and Deep Learning. Future Generation Computer Systems, 2022;130:140-154. Future Generation Computer Systems can be contacted at: Elsevier, Radarweg 29, 1043 Nx Amsterdam, Netherlands. (Elsevier - www.elsevier.com; Future Generation Computer Systems - http://www.journals.elsevier.com/future-generation-computer-systems/)

Our news journalists report that additional information may be obtained by contacting Wanchun Dou, Nanjing University, State Key Laboratory for Novel Software Technology, Nanjing 210023, People’s Republic of China. Additional authors for this research include Guoming Zhang, Xuyun Zhang, Muhammad Bilal, Xiaolong Xu and Joel J. P. C. Rodrigues.

The direct object identifier (DOI) for that additional information is: https://doi.org/10.1016/j.future.2021.12.006. This DOI is a link to an online electronic document that is either free or for purchase, and can be your direct source for a journal article and its citation.

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