Hybrid detection model for unauthorized use of doctor’s code in health insurance: Integrating rule-based screening and LLM reasoning

Key Points

• The hybrid detection model successfully identifies unauthorized use of doctor’s codes by integrating advanced techniques.
• This model combines rule-based screening with LLM reasoning, enhancing accuracy and efficiency.
• Assessment of the system involved extensive data analysis across multiple healthcare datasets, showing promising results.
• The findings highlight the potential for improved fraud detection in health insurance, aiming to minimize unauthorized claims.