Document Type

Article

Publication Title

Journal of Engineering and Computational Intelligence Review

Abstract

The financial waste associated with fraud, abuse, and inefficient claims processing remains a significant challenge to the sustainability of the United States healthcare system, specifically in Medicare and Medicaid programs. The traditional fraud detection systems are mostly reactive, and they are unable to cope up with the increasing volume and complexity of the healthcare claims data. The recent developments in the field of artificial intelligence (AI) present the potential of improving the process of detecting fraud by applying real-time surveillance and predictive analytics. This paper will discuss the perception of stakeholders on the problem of financial waste in the U.S. healthcare system and evaluate how AI-based, real-time fraud detection systems are perceived to address the issue of fraud in Medicare and Medicaid claims. The research design used was cross-sectional, quantitative and it was based on a structured survey instrument. The sample included 250 healthcare stakeholders who included administrators, billing and coding specialists, health IT professionals, policymakers and researchers. The survey involved the assessment of the awareness of financial waste, AI adoption, perceived efficiency of AI-driven fraud detection models, the challenges related to it, and ethics. Reliability analysis and descriptive statistics were used to analyze the data. The statistics indicate that the awareness rate of the respondents regarding financial waste in healthcare is high. There was also high agreement among the respondents about the use of AI and its success in reducing financial waste particularly on real-time fraud detection. Reliability analysis indicated a high level of internal consistency among measurement constructs. Despite the predominantly positive attitudes towards AI effectiveness, the respondents mentioned the challenges related to ethics, regulation, and implementation of AI in respect of data privacy, transparency, and system integration. The paper concludes that AI-informed real-time fraud detection systems are seen by many people as a powerful tool to decrease the financial waste on Medicare and Medicaid claims. Nevertheless, a powerful ethical governance, sufficient infrastructure, and readiness of organizations are necessary to implement it successfully to provide sustainable and responsible adoption.

First Page

71

Last Page

81

Publication Date

Fall 12-31-2024

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