Project News

The GLO+UHC project organized an online workshop to learn Japan's claim review system using AI on 20 October 2021 in response to a strong request from National Health Security Office (NHSO), which pursues digital transformation in the fund management of the Universal Coverage Scheme (UCS).

NHSO has been making serious effort to develop online claim and audit system and computer programs to help processing the enormous amount of healthcare reimbursement data. However, in 2020, a number of fraudulent claims by private facilities were revealed. To further improve the quality and the speed of claim review, NHSO has started considering introduction of "pre-audit" (= claim review) by auditors and AI in earnest. The Secretary-General of NHSO stated as above in a video message to the workshop, which signifies that the introduction of AI to the claim review and audit system is one of their most important issues.

A major claim review organization in Japan named Health Insurance Claims Review & Reimbursement Services (HICRRS) newly introduced AI in September 2021. The project invited a person responsible for the development and maintenance of the AI in HICRRS as a lecturer. He explained their new claim review system, in which 2 types of AI namely Minhash and Xgboost are used for clustering the claims that are difficult to determine whether they are requiring human check or requiring only computer check. Two other Japanese experts also emphasized that introduction of AI to this clustering work enables HICRRS to conduct the clustering quickly and uniformly throughout the country, and thus is expected to improve the quality of claim review.

Around 50 participants from NHSO got many hints from the lecture and Q&A session. The practical knowledge about the process of development of AI seemed particularly useful. The lecturer suggested that the most important thing in introducing AI was to seek an optimal AI system to find inappropriate claims based on the shape and amount of data currently held. It is expected that NHSO is going to examine their dataset and seek the optimal AI system. The project will continuously support NHSO's efforts in development of AI in their claim review system.