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Health insurance fraud is a persistent challenge that affects not only insurers but also, significantly, consumers. When fraud occurs, the costs are inevitably reflected in the price of all users, who already face difficulties accessing quality healthcare. According to the Portuguese Insurers Association (APS), the potential cost of insurance fraud was 67 million euros in 2022. This staggering figure translates into higher premiums and lower quality services for all policyholders, making access to healthcare even more difficult for many families.

In the context of health insurance, the situation becomes even more worrying. The diversity of service providers, the complexity of medical data and the large volume of transactions make the sector especially vulnerable to fraud. Practices such as undue charges, unnecessary procedures and falsification of documents not only burden the system, but also put patients’ health and well-being at risk. Imagine discovering that you’ve been subjected to an unnecessary medical procedure just so someone can make an undue profit, or facing premium increases that jeopardize the family budget.

It is in this alarming scenario that Artificial Intelligence (AI) emerges with a potentially very positive impact. AI has the ability to analyze large volumes of data in real time, identifying patterns and anomalies that would go unnoticed by traditional methods. This enables not only the early detection of suspicious activity, but also the prevention of fraud before it occurs, directly protecting consumers from abusive practices that impact their pockets and their health.

A concrete example of the positive impact of AI on fraud detection can be seen in Australia. Kirontech, a leader in AI solutions for the health insurance sector, in partnership with the ABC television network, identified alarming levels of fraud, waste and abuse in the Australian health system. It found that 86.82% of anesthesiologists charged for anesthesia times that were longer than those compatible with the times recorded by other people in the operating room and with the surgery performed. In addition, 68.36% of anesthesiologists charged for advanced spinal surgeries that were not, in fact, advanced. These figures reveal not only a flawed system, but also the potential direct harm to the patient, both financially and in terms of health. Kirontech is already operating in Portugal, in partnership with leading insurance companies, applying its AI solutions in various areas, such as oncology, radiology and other medical specialties.

Another example of the impact of AI in the fight against fraud in health insurers and hospitals is that of Pindrop, a company specializing in voice authentication and fraud prevention. Pindrop has developed a system that analyzes more than 1,300 unique characteristics of the caller’s voice and device, allowing it to identify fraud attempts such as voice spoofing and other impersonation tactics. This advanced technology has helped insurers and hospitals prevent unauthorized access to sensitive information and avoid fraudulent transactions, ensuring greater security for insurers, hospitals, and their customers.

The implementation of AI in health insurers offers multiple benefits. In addition to cutting costs by reducing financial losses, companies can improve accuracy in detecting suspicious claims and increase operational efficiency. For consumers, this can translate into more affordable premiums and better quality services. Insurers could achieve a return on investment (ROI) of 5 to 15 times the amount invested, which highlights the potential of the technology not only for insurers, but also for the sustainability of the healthcare system as a whole.

The future of AI in health insurance is promising. The trend is for AI to become increasingly integrated into insurers’ processes, which will bring direct benefits to customers, such as faster service, solutions tailored to their needs and, possibly, lower insurance premiums due to reduced operating costs.

Fighting health insurance fraud is essential for the sustainability of the sector and the protection of consumers. Artificial Intelligence is an indispensable ally in this fight, and companies like Kirontech demonstrate that it is possible to combine cutting-edge technology with human expertise to achieve substantial results. At a time when healthcare costs continue to rise, the adoption of AI could be the key to stopping prices from escalating and ensuring that everyone has access to quality healthcare.

 

The article above was first published in Portuguese in ECO Seguros