Published Paper Details:

With the rapid growth of medical costs, the control of medical expenses has been be coming an important task of Health Insurance Department. Traditional medical insurance settlement is paid on a per-service basis, which leads to lots of unreasonable expenses. To cope with this problem, the single-disease payment mechanism has been widely used in recent years. However, the single-disease payment also has a risk of fraud. The in surance industry is a collection of service companies that provide protection services to customers with agreements and agreements from several parties involved. The conven tional mechanism of the insurance claim process has the potential to cause fraud and a high risk that will harm the parties involved. On the other hand, block chain is a technol ogy that one of its features is to provide a ledger where insurance companies can transfer insurance claims to an immutable ledger and help eliminate sources of fraud that are common in the insurance industry. The aim of this research is to help reduce fraud and risk for the insurance industry in general. In this work, proposal of a framework to iden tify fraud of medical insurance based on consortium blockchain and machine learning, which can recognize suspicious medical records automatically to ensure valid implemen tation on single-disease payment and lighten the work of medical insurance auditors. An explainable model is designed to evaluate the reasonability of disease code for Medicare reimbursement by predicting the probability of a disease according to the chief complaint of a patient. Storage and management process of medical records based on consortium blockchain to ensure the security, immutability, traceability, and auditability of the data is also presented