Survey towards Blockchain-Based Healthcare Insurance Fraud Detection

The escalating cost of healthcare has made cost control a critical concern for health insurance agencies. Traditional service-based reimbursement models often result in excessive and unjustifiable claims. Although the single-disease payment model has gained traction to mitigate this, it still presents a considerable risk of fraudulent activities. Insurance operations involve multiple stakeholders and are frequently hindered by outdated, opaque claim processing mechanisms. Blockchain technology, with its immutable ledger and decentralized validation, offers a promising solution to address these inefficiencies and fraud vulnerabilities. This paper proposes a consortium blockchain-based framework enhanced with machine learning to detect fraudulent insurance claims automatically. The system includes an explainable AI component that assesses the legitimacy of medical codes based on patient symptoms. Moreover, the use of blockchain ensures secure, transparent, and auditable storage of healthcare records, thereby assisting auditors and reinforcing trust in the claim settlement process.