Evaluation of the use of computational intelligence techniques in medical claim processes of a health insurance company

Abstract

Brazil has one of the largest private healthcare markets in the world. However, it appears that many indicators of our health insurance companies (including consultations, tests, hospitalizations, etc.) are well above the established international standards. This indicates that many appointments and tests are being carried out without need, generating unnecessary costs on businesses and making the service offered more expensive. In this paper, computational intelligence techniques were used to model the behavior of medical reviewers - professionals who assess whether medical requests should be allowed or not. For the generation of knowledge, a database from a nonprofitable health insurance company containing more than one million records collected since the year 2007 was used. Promising experimental results are presented, indicating that the techniques used can support medical reviewers.