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Globally, 20% to 40% of medical resources are wasted, which could be avoided through professional audit of health insurance claims. The professional audit can pinpoint excessive use of unnecessary medicines and medical examinations. Taiwan’s National Health Insurance Bureau (TNHIB) deducts the weight that medical resources carry if regarded as unnecessary or abused when examining health insurance claims. The ratio of the deducted weight to the total weight claimed by a hospital is defined as the health insurance claim deduction rate (HICDR). A high HICDR increases the operating expenses of the hospital. In addition, it takes the hospital many resources to prepare and file appeals for the deduction. This study aims to: (1) minimize the weight deducted by the TNHIB for a hospital; and (2) facilitate efficient appeals to claim denials. It is expected that HICDR will be reduced through big data analytics. In this study, evidence-based medicine (EBM) is involved to clarify the debate, dilemmas, conflicts of interests in examining health insurance claims. A natural language method—latent Dirichlet allocation (LDA), was used to analyze patients’ medical records. The topics derived from the LDA are used as factors in the logistic regression model to estimate the probability of each claim to be deducted. The experimental results on various medical departments show that the proposed predictive model can produce accurate results, and lead to more than 41.7% reduction to the deduction of the health insurance claims. It is equivalent to more than a 750 thousand NT dollars saving per year. The efficiency of application is validated compared to the manual process that is time-consuming and labor intensive. Moreover, it is expected that this study will supplement the insufficiency of traditional methods and propose a new and effective solution to reduce the deduction rate.

A Decision Support System with Artificial Intelligence and Natural Language Processing to Mitigate the Deduction Rate of Health Insurance Claims