Research code: 403000046
Ethics code: IR.SSU.SPH.REC.1403.125
1- National Center for Health Insurance Research, Tehran, Iran
2- Health Management and Economics Research Center, Health Management Research Institute, Iran University of Medical Sciences, Tehran, Iran
3- Health Policy and Management Research Center, Department of Management and Health Economics, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
4- Health Policy and Management Research Center, Department of Management and Health Economics, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran ,sara.shafaghat@gmail.com
2- Health Management and Economics Research Center, Health Management Research Institute, Iran University of Medical Sciences, Tehran, Iran
3- Health Policy and Management Research Center, Department of Management and Health Economics, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
4- Health Policy and Management Research Center, Department of Management and Health Economics, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran ,
Abstract: (57 Views)
Introduction: Given the significant advancements in Artificial Intelligence (AI) in the health sector and the growing need to optimize health insurance services, leveraging this technology can lead to improved management processes, reduced fraud, optimized costs, and the provision of personalized services for policyholders. This research aimed to investigate the role and functions of AI in health insurance and to present a practical framework for its use in the Iranian health insurance system.
Methods: This applied study was conducted in 2024 using a mixed-methods approach in two main phases: 1) A systematic scoping review to identify the applications of AI in health insurance, and 2) An expert panel to validate the identified components and propose a framework for utilizing AI in Iran's health insurance system.
Results: The systematic scoping review identified 30 eligible studies. Expert panel validation yielded a final framework comprising five main domains and 14 sub-domains for AI application in Iran's health insurance system. The key domains are population health management, fraud detection and prevention, operational productivity enhancement, cost optimization, and policymaking.
Conclusion: Artificial Intelligence plays a pivotal role in enhancing the efficiency and reducing the costs of health insurance systems by leveraging its capacity to analyze vast amounts of health data, predict treatment costs, detect fraud, and automate administrative processes. However, the implementation of this technology necessitates the development of appropriate infrastructure, the formulation of supportive policies, and enhancing awareness among insurance managers and staff. The framework proposed in this study can serve as a practical guide for insurance organizations on the path to optimally utilizing AI.
Methods: This applied study was conducted in 2024 using a mixed-methods approach in two main phases: 1) A systematic scoping review to identify the applications of AI in health insurance, and 2) An expert panel to validate the identified components and propose a framework for utilizing AI in Iran's health insurance system.
Results: The systematic scoping review identified 30 eligible studies. Expert panel validation yielded a final framework comprising five main domains and 14 sub-domains for AI application in Iran's health insurance system. The key domains are population health management, fraud detection and prevention, operational productivity enhancement, cost optimization, and policymaking.
Conclusion: Artificial Intelligence plays a pivotal role in enhancing the efficiency and reducing the costs of health insurance systems by leveraging its capacity to analyze vast amounts of health data, predict treatment costs, detect fraud, and automate administrative processes. However, the implementation of this technology necessitates the development of appropriate infrastructure, the formulation of supportive policies, and enhancing awareness among insurance managers and staff. The framework proposed in this study can serve as a practical guide for insurance organizations on the path to optimally utilizing AI.
Type of Study: Research |
Subject:
Special
Received: 2025/09/20 | Revised: 2025/12/1 | Accepted: 2025/12/1
Received: 2025/09/20 | Revised: 2025/12/1 | Accepted: 2025/12/1
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