An Intelligent Machine Learning Approach for Fraud Detection in Medical Claim Insurance: A Comprehensive Study

Abstract

Medical claim insurance fraud poses a significant challenge for insurance companies and the healthcare system, leading to financial losses and reduced efficiency. In response to this issue, we present an intelligent machine- learning approach for fraud detection in medical claim insurance to enhance fraud detection accuracy and efficiency. This comprehensive study investigates the application of advanced machine learning algorithms for identifying fraudulent claims within the insurance domain. We thoroughly evaluate several candidate algorithms to select an appropriate machine learning algorithm, considering the unique characteristics of medical claim insurance data. Our chosen algorithm demonstrates superior capabilities in handling fraud detection tasks and is the foundation for our proposed intelligent approach. Our proposed approach incorporates domain knowledge and expert rules, augmenting the machine learning algorithm to address the intricacies of fraud detection within the insurance context. We introduce modifications to the algorithm, further enhancing its performance in detecting fraudulent medical claims. Through an extensive experimental setup, we evaluate the performance of our intelligent machine-learning approach. The results indicate significant accuracy, precision, recall, and F1-score improvements compared to traditional fraud detection methods. Additionally, we conduct a comparative analysis with other machine learning algorithms, affirming the superiority of our approach in this domain. The discussion section offers insights into the interpretability of the experimental findings and highlights the strengths and limitations of our approach. We conclude by emphasizing the significance of our research for the insurance industry and the potential impact on the healthcare system's efficiency and cost-effectiveness.