Next-Generation Machine Learning in Healthcare Fraud Detection: Current Trends, Challenges, and Future Research Directions

Abstract

The growing complexity and size of healthcare systems have rendered fraud detection increasingly challenging; however, the current literature lacks a holistic view of the latest machine learning (ML) techniques with practical implementation concerns. The present study addresses this gap by highlighting the importance of machine learning (ML) in preventing and mitigating healthcare fraud, evaluating recent advancements, investigating implementation barriers, and exploring future research dimensions. To further address the limited research on the evaluation of machine learning (ML) and hybrid approaches, this study considers a broad spectrum of ML techniques, including supervised ML, unsupervised ML, deep learning, and hybrid ML approaches such as SMOTE-ENN, explainable AI, federated learning, and ensemble learning. The study also explored their potential use in enhancing fraud detection in imbalanced and multidimensional datasets. A significant finding of the study was the identification of commonly employed datasets, such as Medicare, the List of Excluded Individuals and Entities (LEIE), and Kaggle datasets, which serve as a baseline for evaluating machine learning (ML) models. The study’s findings comprehensively identify the challenges of employing machine learning (ML) in healthcare systems, including data quality, system scalability, regulatory compliance, and resource constraints. The study provides actionable insights, such as model interpretability to enable regulatory compliance and federated learning for confidential data sharing, which is particularly relevant for policymakers, healthcare providers, and insurance companies that intend to deploy a robust, scalable, and secure fraud detection infrastructure. The study presents a comprehensive framework for enhancing real-time healthcare fraud detection through self-learning, interpretable, and safe machine learning (ML) infrastructures, integrating theoretical advancements with practical application needs.

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