2022 International Conference on Disruptive Technologies for Multi-Disciplinary Research and Applications
Medical Insurance Fraud Detection Based on Block
Chain and Deep Learning Approach
2022 International Conference on Disruptive Technologies for Multi-Disciplinary Research and Applications (CENTCON) | 978-1-6654-6374-4/22/$31.00 ©2022 IEEE | DOI: 10.1109/CENTCON56610.2022.10051253
Bijaya Kumar Sethi Debabrata Singh
Department of Computer Science and Department of Computer Applications
Engineering Siksha 'O' Anusandhan,(Deemed to be
Siksha 'O' Anusandhan,(Deemed to be University), Bhubaneswar, India
University), Bhubaneswar, India debabratasingh@soa.ac.in.
sbijayakumar@gmail.com
Abstract-To control the medical expenses people are
decided to do some insurance plans and the Health
Insurance Department's duty of controlling medical
expenses has become increasingly vital. Traditional medical
insurance settlements are paid per-service, which results in a
lot of unnecessary costs. Now a day, the single-disease
payment mechanism has been frequently employed to
address this issue. However, there is a possibility of fraud
with single-disease payments. In this work, we have
presented a methodology for detecting the health insurance
fraud entrenched block chain and deep learning techniques,
that can automatically recognize apprehensive medical
records to assure sustainable execution of single-disease
payment and reduce medical insurance worker’s workload.
We also proposed a medical record storage and management
procedure based on consortium block chain to assure data
security, immutability, traceability, and audit ability. The
suggested system may effectively identify fraud and
considerably increase the efficiency of medical insurance
evaluations, as demonstrated by experiments on two real
datasets from two hospitals.
Keyword: Fraud Detection, Block Chain, Medical Insurance,
CNN, RNN, Deep Learning, International Classification of
Diseases ( ICD)
I. INTRODUCTION
The expeditious rise of medical information has
resulted in a massive amount of data beingaccumulated in
hospital information systems, propelling the medical
industry into big data creation. The medical field has
benefited greatly from hospital big data, which has sparked
a lot of interest from the academia and industry. Medical
cost control is a major section of big data research in
medical science. Under the conventional insurance system
in healthcare, expenses are reimbursed based on service
items provided by hospitals that give rise to immoderate
medicinal treatment and increase treatment prices. To
address the concerns with components based pricing
methods, Single illness Payment depending upon detection
oriented groups which have been considerably
investigated, deployed. Under single Disease payment
method, each disease has a predetermined payment
standard. Hospitalization costs are reimbursed by the social
healthcare insurance organization based on the disease's
prescribed standard [1].
To get a better knowledge that differentiate a single
illness payment system and a product based payment
technique, consider the following example. As per the usual
health insurance settlement method, if a patient's detection is
cancer and the health insurance prices are 200,000 rupees
978-1-6654-6374-4/22/$31.00 ©2022 IEEE
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Prakash Kumar Sarangi
Department of CSE (AI & ML)
Vardhaman College of Engineering,
Hyderabad, India
prakashsarangi89@gmail.com
and the recompensing ratio is 80%, the recompensing
charge will be 160,000 rupees. In the Diagnosis Related
Groups payment model, if the Diagnosis Related Groups
weighting rate for cancer is 7.4 and the payment per unit
price is 15,000 rupees, the health insurance have to
compensate 87,800 rupees [2].
After the single-disease payment method is established,
hospital income is hardly associated with every medical
case and detection of disease, and nothing can be done with
a patient's real treatment costs. If the treatment expenses for
a condition are higher than the group's average, hospitals
must reimburse the difference in order to better control
medical insurance costs.
It can make consistent uses of medical asset i.e., medical
institution consumption is corresponding to the number of
patients admitted, disease complication, and service
strength. To summarize, the single-illness payment model
creates a defined health insurance payment criterion for
every disease in order to reduce hospital expenditures by
preventing excessive medical behavior. This approach
ensures that medical services are of high quality while
remaining simple to utilize.
Chief complaint describes the symptoms or conditions of a
patient, as well as the duration of difficulties, that the
physician records in the patient's clinical report. Chief
complaint is the primary object in the clinical report. This
should articulate the features of the initial disease
identification; its representation should be brief, polished,
and correct, with not more than 30 characters in the Chinese
electronic medical record's writing requirements.
International Classification of Diseases (ICD) is a
globally standardized illness categorization system that
uses a coding system to categorize diseases based on
morphology, embryology, physical environment, and
clinical substantiations. The World Health Organization
created it, and it's generally used in the area of health care
techniques for things like determining the reason of death,
illness demography and summarizing, evaluating medical
feature, and medical compensation.
II. RELATED WORK
In order to uncover inaccurate clinical reports, the feasibility
of the illness identified must be checked depending on the
patients' primary symptoms. To do this, the goal of
identifying treacherous medical records is transformed into
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a text classification task, where we forecast the likelihood of
every ICD 10 category based on a major complaint. After
that, every ICD 10 codes' projected probability shall be
arranged in decreasing order. Medical record will be
regarded plausible if the ICD 10 code allocated to it is
among the top-k set of projected results. Otherwise, it will
be deemed a scam and will require human auditing. The k
value may be derived based on the circumstances, and a
higher value of k indicates that stringent auditing is less [4]
[5].
Fig 1: Model for anti-fraud Detection System
Above Fig-1 indicates, the general anti fraud detection
system used in the medicals. In this paper section 3
discussed about proposed work and section 4 produces
experimental results and analysis. Finally, in the section 5
we have concluded our proposed work and also mention
some model for future study.
III. PROPOSED WORK
In this paper our methodology moves in a pipe line way.
First we have collected data from different sources, in
second step we have to store m e d i c a l records and
management using Block chain technology, and at last we
will classify these dataset using Deep Learning techniques.
A. Storage of m e d i c a l records and management
using Block chain technology
Primary complaints and ICD are crucial proof in antifraud
investigations. We provide a block chain based framework
for medical data storage and administration in order to
provide strong tamper resistance, anti repudiation,
reliability, and incorruptibility protection. Our key
contributions to the proposed framework are in the
following three areas:
• We have created a data storage approach which
minimizes depot capacity and enhances the
performance of block chain, based on features
of medical data.
• To improve block chain consensus efficiency, we
have optimized the agreement process through
splitting block chain vertices as agreement
vertices and application vertices.
• We h a v e created a smart contract-based system
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for storing and querying medical data that
ensures tamper-proofed, tractability, and
authenticity of medical information.
Fig 2: Medical system based on b l o c k chain
Through transparency and trust standards, block chain
technology manages the production, ingress, and utilization
of reliable data. A peer-to-peer network typically manages a
block chain, and the data saved on the block chain is un-
modifiable, remarkable, and tractable. Block chain is a
comprehensive solution in terms of technical architecture,
encompassing distributed storage, block-chain data
structures, peer- to-peer networks, consensus algorithms,
cryptography algorithms, game theory, smart contracts, and
other data AI technologies [9].
Public, private, and consortium block chains are the three
basic types of block chain systems. A public chain is one in
which anybody, even anonymously, can participate. A
private block chain is one that is managed and used only
within a firm [8].
In the figure 2, we have suggested medical block chain
structure. Regulatory agencies, hospital insurance centers,
hospitals, and doctors are among the block chain's users. A
doctor creates an electronic medical record [10]. On upload
the medical record to the block chain, the doctor must
digitally sign it and initiate a transaction. The medical
record will then be reviewed by the doctor's facility and
digitally signed for block chain certification. The Medical
Insurance Centre analyses block chain data to assess the
validity of disease diagnoses and audits questionable
medical records. To synchronies all information for
inspection and tracking the universal trafficking process,
regulatory bodies can connect to the block chain as a vertex
or communicate with it via terminals [6][7].
B. Classification using Deep Leaning Techniques
The health insurance center's staff examines the block chain
for relevant medical data and signatures during physical
audits, and then connects them to linked doctors and
hospitals. Doctors, hospitals, and medical insurance
companies will sign the audit results, which will then be
kept on the block chain. Medical insurance fraud behavior
by doctors and hospitals will be penalized, and the frauds
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will be documented on their credit reports. Doctors and diagnostic codes entered by doctors at the time of
hospitals with bad credit may face further restrictions from admission. We simply used the initial 3 figures of every
the medical insurance center. Using these datasets, we have ICD code in the studies. The databases are sparse and
to classify into two part one side having fraud and another imbalanced since more of the IC codes are only
not fraud. These binary classifications are performed assigned to a less amount of primary complaints. As a
through Text CNN Character, Text CNN word, DPCNN's result, there is a need for data preprocessing. ICD 10
network, Text RNN, HAN, First Text, and LEAM [3][11]. codes with a numerical value of less than 500 have been
phased out.
A standard CNN based text classification method.
Text CNN uses numerous one dimensional convolution
kernels to study the characteristic presentations of
phrases, giving it a great capacity to extract shallow text
features. Due to its good outcome and quick training
fastness, it is universally employed in brief language
classification. DPCNN is a language classification
technique that uses major CNN layers to apprehend a
text's extended-distance protectorate and outperforms
several other methods. The RNN is a classic successive
description approach that excels at modeling text
sequences of varied lengths while capturing natural
language features. Researchers have a strong desire to
employ RNNs rather than Convolutional Neural
Networks in numerous Natural language processing
jobs. In this research, the Recurrent Neural Network
network contains of 2 layers of LTSM Networks. The
input alphabets are initially submerged, and then the Fig. 3: Precision, Recall, and F1 Score for First data set
submerging outputs are passed to 2 layers of LSTM.
The results from the LSTM layers are then input into a In the figure 3, X-axis conations different deep learning
fully layer which are fully connected. Finally, the Soft techniques, and Y-axis contains Precision, Recall, and F1
Max algorithm is used to calculate the ICD-10 code Score for different models. For the first dataset for the
expected possibilities. A hierarchical RNN containing models Text CNN Character, Text CNN word, DPCNN's
attention mechanisms is known as a Hierarchical network, Text RNN, HAN, First Text, and LEAM,
Attention Network (HAN). Before applying excerptor precision are 97.61, 97.72, 97.60, 97.28, 96.98, 96.71,
and observation to the tokens and phrases, the system 97.56, Recalls are
separates the text into a group of expressions. Because 95.71, 95.22, 95.59, 95.48, 96.91, 93.02,95.33, and F1
the sentences in our dataset are brief, they are not split.
Scores are 96.55, 96.12, 96.47, 96.27, 96.88,94.50,96.30
First Text is a word classification and respectively.
characteristics presentation research tool proposed by
Face book that makes word classification and
characteristics presentation research simple and
efficient. It produces similar outcomes as deep learning,
but at a much rapidly. LEAM is a new text classification
attention model. It combines the training of words and
labels in order to acquire their embedding in the same
vector space. It offers a faster convergence time and
requires less parameter than other deep learning
approaches.

IV. EXPERIMENTAL RESULTS AND ANALYSIS

We have taken two hospital data sets form medicals

in Jiangsu Province, China (hospital-X and hospital-Y)
having number of patient’s data 198810 and 434319
respectively. Based on the analysis each hospital data
Fig 4: Precision, Recall, and F1 Score for second dataset
set contains only 8 diseases identified and using block
chain created a new dataset which patients are having
insurance or card or not. The implementations are made In the figure 4, X-axis conations different deep learning
using python3 programming language, with system techniques, and Y-axis contains Precision, Recall, and F1
specifications 8 GB RAM and i5 processor. The ICD Score for different models. For the first dataset for the
codes were taken from the main page of hospital models Text CNN Character, Text CNN word, DPCNN's
databases, while the major complaints of sick persons network, Text RNN, HAN, First Text, and LEAM,
were taken from admittance registers. Because expert precision are
coders have changed ICD codes in the main page of 96.60, 96.04, 96.16, 95.78, 96.05,96.52,95.31, Recalls are
hospital reports as per the whole medical information of 90.85, 90.38, 90.61, 90.53, 90.72, 86.44,89.92, and F1
the admitted patients, they are more accurate than the
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Scores are 93.28, 92.86, 93.03, 92.79, 93.06,89.85,92.59 functions.
respectively.
Convolutional Neural Network based methods outperform
RNN based, with LEAM being the worst performer. [1].
DPCNN's network is larger, but it doesn't outperform Text
CNN's, likely because the main complaint's text is short, and
our assignment does not take use of its advantage of mining
[2].
remote relationship characteristics. The performance of
HAN is marginally better than that of regular RNN, but the [3].
changes are minor, showing that the observation procedure
provides unimportant benefit in the brief main complaint. [4].
V. CONCLUSION AND FUTURE WORK
[5].
For detecting fraud in health insurance, this paper’s
primarily the block chain. It forecasts the possibility of an
illness based on a sick person’s principal complaint and
calculates the validity of the ICD code entered in the [6].
health report using label and character representations. We
have presented a solution for storing and managing
[7].
medical records that is depends on block chain
methodology, which ensures information security,
reliability, immutability, traceability, and authentication.
The suggested method has the potential to reduce [8].
healthcare insurance brokers' burden while also enhancing
efficiency. According to trials on authentic datasets from
two reputed hospitals, our approach may efficiently
execute antifraud for health insurance and has well [9].
interpretability. We have applied seven deep learning
models for classification purpose. Convolutional Neural
Network based methods outperform RNN based, with
LEAM being the worst performer. DPCNN's network is [10].
larger, but it doesn't outperform Text CNN's, likely
because the main complaint's text is short, and our
assignment does not take use of its advantage of mining
[11].
remote relationship characteristics. The performance of
HAN is marginally better than that of regular RNN, but
the changes are minor, showing that the observation
procedure provides unimportant benefit in the brief main
complaint. In future we have to enhance the same into
other deep learning models with different activation
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