News Middle East08 Oct 2018

UAE:AI model helps insurers detect waste in healthcare

08 Oct 2018

Artificial intelligence (AI) applied by health insurers could help save millions of dirhams a year in fraud and abuse within the UAE healthcare system, analysts say.

Swiss software company Netcetera has completed a successful trial of its latest technology using an AI model in a major health insurer, spotting almost 37,000 suspicious claims made by more than 4,000 doctors between 2016-17, reports The National.

The suspicious claims detected totalled AED21m ($5.7m) and would normally have gone unnoticed by insurers, who would end up paying for unnecessary treatments given by hospitals and clinics.

The AI model built into the claim system will recognise pattern of prescriptions and raise a red flag when a doctor delivers an abnormal course of treatment.

Mr Kiril Milev, managing director of Netcetera Middle East, said, “In many cases, suspect claims are not always fraudulent, but can be general misuse and waste.

“If doctors don’t want to take risks, they will prescribe the most expensive treatment available. This is not always appropriate.

“Sometimes members will try to get some kind of care or treatment they are not entitled to.

“In general, waste and abuse is happening everywhere but in countries like the UAE, the problem is systematic as it is driven by the way people are contracted to offer certain treatments to avoid risk and maximise profits.”

Over-prescription has been a common problem in the country, wasting billions of dirhams each year. Doctors who regularly over-prescribe risk being blacklisted by insurance companies.



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