| 의료감사에서의 인공지능 기술 활용: 기회와 도전과제 |
심보람
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| 건강보험심사평가원 심사평가정책연구소 부연구위원 |
| Leveraging Artificial Intelligence in Medical Audit: Opportunities and Challenges |
| Boram Sim
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| Associate Research Fellow, HIRA Research Institute, Health Insurance Review and Assessment Service, Wonju, Korea |
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Received: December 18, 2024; Accepted: February 20, 2025. |
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| ABSTRACT |
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Medical audit refers to the process of systematically reviewing patients’ medical records, billing data, and other data according to cost and quality standards. This study reviewed the applicability, opportunities, and challenges of artificial intelligence (AI) technology in the field of medical audit. Medical audits ensure that insurers provide quality healthcare services and that prevent inadequate expenditures; however, it is a complex and time-consuming task. AI Technology can greatly improve this process. Specifically, AI can reduce claims errors for health care providers, automate the audit process, or support the decision-making of the reviewer, thereby reducing the time and cost required for medical audit. Furthermore, AI technology can detect patterns or anomalies that humans may overlook, facilitating the early identification of potential issues. This enables AI to improve the operational efficiency and accuracy of medical audits, and ultimately contributing to the enhancement of services provided to patients. Nevertheless, technical and ethical challenges such as data quality, fairness, and transparency persist. To address these challenges, close collaboration among the medical community, technical experts, and policymakers is essential. Additionally, empirical research on actual application cases of AI and their outcomes is necessary. |
| Key words:
Artificial intelligence, Medical audit, Insurance claim review, Health insurance, Fraud detection |
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