Automatic Recommender System of Development Platforms for Smart Contract-Based Health Care Insurance Fraud Detection Solutions: Taxonomy and Performance Evaluation.

BACKGROUND

Health care insurance fraud is on the rise in many ways, such as falsifying information and hiding third-party liability. This can result in significant losses for the medical health insurance industry. Consequently, fraud detection is crucial. Currently, companies employ auditors who manually evaluate records and pinpoint fraud. However, an automated and effective method is needed to detect fraud with the continually increasing number of patients seeking health insurance. Blockchain is an emerging technology and is constantly evolving to meet business needs. With its characteristics of immutability, transparency, traceability, and smart contracts, it demonstrates its potential in the health care domain. In particular, self-executable smart contracts are essential to reduce the costs associated with traditional paradigms, which are mostly manual, while preserving privacy and building trust among health care stakeholders, including the patient and the health insurance networks. However, with the proliferation of blockchain development platform options, selecting the right one for health care insurance can be difficult. This study addressed this void and developed an automated decision map recommender system to select the most effective blockchain platform for insurance fraud detection.

OBJECTIVE

This study aims to develop smart contracts for detecting health care insurance fraud efficiently. Therefore, we provided a taxonomy of fraud scenarios and implemented their detection using a blockchain platform that was suitable for health care insurance fraud detection. To automatically and efficiently select the best platform, we proposed and implemented a decision map-based recommender system. For developing the decision-map, we proposed a taxonomy of 102 blockchain platforms.

METHODS

We developed smart contracts for 12 fraud scenarios that we identified in the literature. We used the top 2 blockchain platforms selected by our proposed decision-making map-based recommender system, which is tailored for health care insurance fraud. The map used our taxonomy of 102 blockchain platforms classified according to their application domains.

RESULTS

The recommender system demonstrated that Hyperledger Fabric was the best blockchain platform for identifying health care insurance fraud. We validated our recommender system by comparing the performance of the top 2 platforms selected by our system. The blockchain platform taxonomy that we created revealed that 59 blockchain platforms are suitable for all application domains, 25 are suitable for financial services, and 18 are suitable for various application domains. We implemented fraud detection based on smart contracts.

CONCLUSIONS

Our decision map recommender system, which was based on our proposed taxonomy of 102 platforms, automatically selected the top 2 platforms, which were Hyperledger Fabric and Neo, for the implementation of health care insurance fraud detection. Our performance evaluation of the 2 platforms indicated that Fabric surpassed Neo in all performance metrics, as depicted by our recommender system. We provided an implementation of fraud detection based on smart contracts.

Informations de copyright

©Rima Kaafarani, Leila Ismail, Oussama Zahwe. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 18.10.2024.