How AI and ML can solve the problem of medical fraud

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Shiraaz Joosub | Sales Executive | Healthcare | T-Systems South Africa | mail me


Medical malpractice litigation costs South Africa millions of Rands every year and drives up the cost of healthcare. While some claims of medical negligence have merit, the unfortunate reality is that there has been a spike in fraud in this area since 2017.

Over the years, this has cost Government billions and has had a devastating effect on the country’s public healthcare sector.

Now, in the wake of the COVID-19 pandemic, it is more important than ever to stop medical fraud in its tracks and reduce medical malpractice.

Fortunately, data analytics, Artificial Intelligence (AI) and Machine Learning (ML) can assist greatly in developing a digital audit trail to protect healthcare providers against fraudulent medical malpractice claims.

A cost beyond billions

In 2018 the Special Investigations Unit (SIU) began investigating medical fraud in the Eastern Cape and Gauteng, after a spike of R8.4 billion in medical negligence claims. They implicated the Office of the State Attorney and uncovered a trend of ‘ghost claims’, where unscrupulous individuals received pay-outs instead of the real beneficiary.

In addition, in the same year, the SIU investigated a long-running medical malpractice scam involving collusion between law firms and state attorneys that has cost government at least R60 billion.

This clearly indicates the huge financial cost of medical malpractice, which is further compounding rising healthcare costs.

However, the effects of increased medical malpractice claims go beyond just finance. Not only does it erode confidence in healthcare, it also creates an environment where doctors become fearful of performing certain emergency or high-risk procedures due to the possibility that they may be sued.

The net result is that funds that could be re-invested into healthcare provision are instead being spent of defending medical malpractice litigation. This creates a gap in healthcare service provision, reducing access to safe and affordable healthcare

How medical malpractice claims are twisted to fraud

While there are obviously legitimate claims resulting from medical malpractice, these claims are often convoluted.

Legal teams work in syndicates to obtain higher settlement values than incidents may justify, including general damages or patient’s loss of earning capacity, which can be difficult to quantify.

In addition, as previously mentioned, ghost claims arise where instances of genuine malpractice are paid out to the wrong beneficiary.

Technology solutions for better record keeping

Most hospitals, particularly those in the public sector, lack the technology required to track, trace and audit activities throughout patient care. This is where those with unscrupulous intentions take advantage, and medical malpractice fraud arises.

Implementing electronic patient records with appropriate security measures in place can go a long way in ensuring patient data is recorded and maintained safely. This can also make data more accessible and portable, so that it can be shared effectively – another must when it comes to detecting and preventing fraud.

In addition to providing an effective audit trail to prevent fraud around medical malpractice claims, electronic record keeping can protect patients as well.

Patient records that are correctly managed through Healthcare Information Systems (HIS) can provide the necessary data and intelligence that hold physicians accountable for the diagnosis and treatments of their patients.

Adding intelligence to the mix

Data analysis and machine learning offer a powerful addition to HIS, helping to identify when physicians deviate from pre-defined clinical pathways, thus assisting with preventing medical malpractice from occurring.

Additionally, technology, ML and AI play a significant role in baselining patient data. The analysis of this data compared to historical data or benchmarked metrics using algorithms serves as an invaluable tool to identify potentially fraudulent claims of medical malpractice.

The predictive approach of ML will ensure continuous audit of data, screening of loopholes for fraudulent activity and the necessary security to protect patient information.

Making HIS affordable

The capital expense typically associated with the adoption of HIS has perpetuated paper-driven patient records and processes in the South African healthcare space, leaving vulnerabilities for medical malpractice and fraud.

However, new technology evolutions such as managed services make innovative HIS cost effective as an operational expense. This helps to ensure safe, easily accessible and secure patient records virtually via private or public cloud.

The managed services component of the HIS also reduces the running costs making it more affordable and accessible.

Patient records become accessible, safe, secure, portable and scalable, and widespread adoption of secure digital technologies helps to safeguard against fraud and medical malpractice.

In addition, AI and machine learning can be used better manage patient outcomes and deliver innovative healthcare solutions.


 



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