How AI is transforming fraud detection in healthcare

Kolla, Triveni (2025) How AI is transforming fraud detection in healthcare. World Journal of Advanced Research and Reviews, 26 (2). pp. 3674-3681. ISSN 2581-9615

Healthcare fraud presents a formidable challenge to modern healthcare systems worldwide, with substantial financial losses and erosion of patient trust. Traditional detection methodologies based on rule frameworks and manual review processes have proven inadequate, generating excessive false positives and missing complex fraud patterns. The healthcare sector's digital transformation has created unprecedented opportunities to leverage artificial intelligence for fraud prevention. This article examines how AI technologies—including machine learning algorithms, natural language processing, and network analytics—are revolutionizing fraud detection capabilities. Advanced systems now integrate data from previously siloed sources, transform raw information into meaningful features, and employ specialized training frameworks to enhance detection accuracy while reducing false positives. The integration of these technologies enables a fundamental shift from retrospective to proactive fraud management, with suspicious patterns identified in near real-time before payment execution. Despite significant technological advances, optimal approaches balance AI capabilities with human expertise through structured feedback mechanisms. As these technologies mature, emerging frontiers include real-time prevention mechanisms, predictive risk analytics, cross-payer collaboration, blockchain integration, and quantum-inspired detection capabilities, transforming healthcare fraud management from a cost center to a strategic asset ensuring healthcare sustainability.