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At least 19 recordsLinked to original sources
PubMed2026

Improving insurance deduction identification: a hybrid artificial intelligence model using machine learning and expert systems.

PURPOSE: Financial challenges in healthcare systems worldwide, especially in low- and middle-income countries like Iran, have increased hospitals' reliance on insurance reimbursements. Unrecognized insurance deductions often cause severe financial shortages, making efficient deduction management crucial. This study aimed to design a hybrid intelligent system for identifying and predicting insurance deductions by combining machine learning and expert system frameworks. DESIGN/METHODOLOGY/APPROACH: A mixed-methods design was applied in four stages. First, a scoping review identified the causes and patterns of insurance deductions. Second, interviews with 15 insurance experts produced a validated checklist and a dataset from inpatient billing records. Third, using the CRISP-DM methodology, machine learning algorithms were developed and tested in SPSS Modeler alongside a fuzzy expert system developed in MATLAB. Finally, the model was validated using the holdout method. FINDINGS: Four categories of deduction drivers were identified: service provision, registration errors, document submission issues, and revenue conversion processes. The CHAID decision tree outperformed other algorithms with a 99% precision rate and the lowest Mean Absolute Error (9.43). A brief assessment of potential overfitting was conducted to ensure that the CHAID model's high accuracy was interpreted cautiously and supported by the validation results. The fuzzy expert system with validated rules was adaptable for deduction classification, especially for cases unsuitable for quantitative modeling. ORIGINALITY/VALUE: The hybrid model improves detection and prevention of deductions, offering actionable insights for hospital administrators, insurers, and policymakers. Its implementation can enhance hospital information systems, streamline claims processing, and optimize revenue management amid financial constraints.

Machine Learning↗
PubMed1990

Waivers of insurance deductibles--charity or crime?

Many physicians occasionally waive insurance deductibles and copayments for their patients. Some do it routinely and advertise the fact. Aetna Life Insurance Company in 1988 called this practice fraud, a position The National Health Care Anti-Fraud Association subsequently took (1). However, it is all too easy to apply that label without analyzing the facts. This article examines the practice of waiving copayments and deductibles, describes recent developments in the area, and offers some guidelines for physicians.

Crime↗
PubMed2001

The effect of variable health insurance deductibles on the demand for physician visits.

In order to contain cost in the health care sector, the introduction of consumer incentives in health insurance has been suggested and realized in many countries. The Swiss health system reform of 1996 introduced a choice of deductible for health services in the mandatory basic health insurance. This paper estimates the effect of this choice on physician service utilization. A generalized method of moments (GMM) estimator is applied to take account of the endogeneity of the choice of the deductible in the estimation of the number of physician visits. This paper finds that most of the observed reduction in the number of physician visits among individuals who choose a higher deductible seems to be a result of self-selection of individuals into the respective insurance contracts, and not to induced changes in utilization behaviour.

Adolescent↗
PubMed1983

Social Security benefits; disability insurance benefits; deductions, reductions, and nonpayments of benefits--SSA. Final rules with comment period.

These regulations amend the existing regulations under which Social Security benefits payable to a disabled worker and his or her family may be reduced because of the worker's concurrent entitlement to workers' compensation benefits. They provide that entitlement to certain other public disability benefits may reduce the disability benefits paid by Social Security; that the reduction applies to the first month of concurrent entitlement regardless of the month in which we are notified of entitlement to the public disability benefit; and that the reduction applies to all months of concurrent entitlement until the disabled worker attains age 65. These regulations also provide that where a public disability law or plan provides for reduction of the public disability benefit on the basis of entitlement to Social Security disability insurance benefits that provision will preclude reduction of the Social Security benefits but only if it was in effect on February 18, 1981. These regulations implement section 2208 of the Omnibus Budget Reconciliation Act of 1981 (Pub. L. 97-35).

Social Security↗
PubMed2000

Deductibles in health insurance: can the actuarially fair premium reduction exceed the deductible?

The actuarially fair premium reduction in case of a deductible relative to full insurance is affected by: (1) out-of-pocket payments, (2) moral hazard, (3) administrative costs, and, in case of a voluntary deductible, (4) adverse selection. Both the partial effects and the total effect of these factors are analyzed. Moral hazard and adverse selection appear to have a substantial effect on the expected health care costs above a deductible but a small effect on the expected out-of-pocket expenditure. A premium model indicates that for a broad range of deductible amounts the actuarially fair premium reduction exceeds the deductible.

Actuarial Analysis↗
PubMed1993

Psychosocial effects of cancer economics on patients and their families.

Cancer frequently follows an unpredictable course, with patients experiencing numerous disruptions in their lives. Concomitantly, the enormous financial burdens that accompany the onset and subsequent treatment of cancer become even more overwhelming. Regardless of socioeconomic status, almost all families confronted with cancer and its treatment will have financial problems. Poor people are more likely to be diagnosed with cancer when the disease is advanced and treatment options are significantly more limited. Limited access to medical care carries the additional risk of denied access to community resources, which often are made through referrals from the health care system. For the middle-class family with insurance, as medication costs increase (whether they are covered or not), financial deprivations accumulate as out-of-pocket expenditures, because of required insurance deductibles and copayments and wages lost because of aspects of the treatment. Therefore, even those who are insured can be financially devastated by substantial gaps in coverage. A diagnosis of cancer compounds the struggle for survival and introduces new financial, physical, and psychologic demands. As a nation, we must ensure that cancer prevention, detection, treatment, and rehabilitation services are accessible and available to all who need them, regardless of their ability to pay.

Cost of Illness↗
PubMed1984

Epidemiologic study of dental emergencies among utilizers in an insured population in Washington, USA.

This is a study of the epidemiology of dental emergencies based on information abstracted from the microfilmed dental claim forms of a large American insurance program in 1981-82. Overall, about 4% of all dental visits were classifiable as emergencies. There were significant seasonal and age variations in dental emergencies. There was no variation with respect to geographic regions in the State of Washington (USA) or sex. Paradoxically, residents in regions having fluoridated water supplies were at equal risk of developing dental emergencies due to dental caries, relative to those residing in non-fluoridated regions. There was also no difference in risk associated with insurance deductibles, although generally deductibles are thought to deter first-contact visits.

Adolescent↗
PubMed2006

A review of data on the U.S. health sector: summer 2005.

This report presents information on the state of the U.S. health sector in late summer 2005. It includes data on the uninsured and underinsured and their access to health care, on socioeconomic inequalities in health care, and on the rising costs of health insurance. It also presents information on the role of corporate money in health and health care, focusing on the pharmaceutical and hospital industries. The authors include an update on Medicare HMOs and the prescription drug bill, the results of some recent public opinion polls on health care, and some international comparisons of health systems. The article ends with recent data on health (medical) savings accounts and high-deductible insurance plans.

Canada↗
PubMed2003

Deductibles in health insurance: pay or pain?

We study a health-insurance market where individuals are offered coverage against both medical expenditures and losses in income due to illness. Individuals vary in their level of innate ability and their probability of falling ill. If there is private information about the probability of illness and an individual's innate ability is sufficiently low, we find that competitive insurance contracts yield screening partly in the form of co-payment, i.e., a deductible in pay, and partly in the form of reduced medical treatment, i.e., a deductible in pain.

Consumer Behavior↗