Ketankumar Patel
Ketankumar Patel
Senior Software Engineer, Anaqua Inc
AI for Healthcare Fraud Detection and Operational Intelligence
Modern healthcare networks are processing millions of administrative transactions every day, resulting in a massive wave of fragmented, siloed data that leaves organizations vulnerable to severe financial leakage. This presentation examines the operational challenges of healthcare fraud, waste, and abuse, demonstrating how legacy, rule-based systems fail to stop sophisticated tactics like duplicate billing, phantom claims, unnecessary care, and upcoding. To address these vulnerabilities, the talk details how Artificial Intelligence (AI) transforms compliance workflows from reactive post-payment auditing to real-time risk mitigation. It explores the practical deployment of machine learning pillars—including multi-dimensional anomaly detection, predictive risk scoring, Natural Language Processing (NLP) for clinical document alignment, and Graph Intelligence to expose hidden collusion networks. Finally, the session outlines the operational outcomes of AI-driven automation and addresses the critical governance, security (HIPAA), explainability, and human oversight frameworks required to build sustainable, intelligent healthcare systems.