Leveraging Artificial Intelligence in Medical Audit: Opportunities and Challenges

Medical audit refers to the process of systematically reviewing patients’ medical records, billing data, and other data according to cost and quality standards. This study reviewed the applicability, opportunities, and challenges of artificial intelligence (AI) technology in the field of medical audit. Medical audits ensure that insurers provide quality healthcare services and that prevent inadequate expenditures; however, it is a complex and time-consuming task. AI Technology can greatly improve this process. Specifically, AI can reduce claims errors for health care providers, automate the audit process, or support the decision-making of the reviewer, thereby reducing the time and cost required for medical audit. Furthermore, AI technology can detect patterns or anomalies that humans may overlook, facilitating the early identification of potential issues. This enables AI to improve the operational efficiency and accuracy of medical audits, and ultimately contributing to the enhancement of services provided to patients. Nevertheless, technical and ethical challenges such as data quality, fairness, and transparency persist. To address these challenges, close collaboration among the medical community, technical experts, and policymakers is essential. Additionally, empirical research on actual application cases of AI and their outcomes is necessary.