AntAkso: Claims Management System for Health Insurance in Alipay

摘要

The rapid growth of health insurance and the rising incidence of fraudulent claims underscore the necessity for an efficient and professional claims management system. However, there is a noticeable lack of shared relevant experience from previous research in this field. In response to this challenge, we introduce AntAkso, a robust claims management system specifically designed for health insurance operations within Alipay. AntAkso incorporates a digital and professional management system, achieving a notable decrease in the volume of false claims, reduction in administrative costs, and heightened satisfaction among its policyholders. We begin by highlighting the core components of this system, including the case stratification, hospital recommendation, and case dispatch modules, along with the pivotal algorithms employed, i.e., the fraud detection, recommendation, and robust satisficing algorithms. We also detail the system's implementation and deployment. We substantiate the proposed system's effectiveness and efficiency with empirical evidence from experiments on a large set of real-world health insurance claims data.