Towards a Secure Technology-Driven Architecture for Smart Health Insurance Systems: An Empirical Study

Health insurance has become a crucial component of people’s lives as the occurrence of health problems rises. Unaffordable healthcare problems for individuals with little income might be a problem. In the case of a medical emergency, health insurance assists individuals in affording the costs of healthcare services and protects them financially against the possibility of debt. Security, privacy, and fraud risks may impact the numerous benefits of health insurance. In recent years, health insurance fraud has been a contentious topic due to the substantial losses it causes for individuals, commercial enterprises, and governments. Therefore, there is a need to develop mechanisms for identifying health insurance fraud incidents. Furthermore, a large quantity of highly sensitive electronic health insurance data are generated on a daily basis, which attracts fraudulent users. Motivated by these facts, we propose a smart healthcare insurance framework for fraud detection and prevention (SHINFDP) that leverages the capabilities of cutting-edge technologies including blockchain, 5G, cloud, and machine learning (ML) to enhance the health insurance process. The proposed framework is evaluated using mathematical modeling and an industrial focus group. In addition, a case study was demonstrated to illustrate the SHINFDP’s applicability in enhancing the security and effectiveness of health insurance. The findings indicate that the SHINFDP aids in the detection of healthcare fraud at early stages. Furthermore, the results of the focus group show that SHINFDP is adaptable and simple to comprehend. The case study further strengthens the findings and also describes the implications of the proposed solution in a real setting.