SUSESO's AI Strategy for Medical License Fraud Detection

Source: Diario Financiero, Marco Zecchetto, 12 November 2024
URL: https://www.df.cl/df-lab/transformacion-digital/la-estrategia-de-la-suseso-para-identificarlicencias-medicas-falsas-y

The Superintendencia de Seguridad Social (SUSESO) is implementing an artificial intelligence initiative to combat fraudulent medical licenses and enhance claim responses. Superintendent Pamela Gana outlined a portfolio of 11 projects spanning three years, with six focused specifically on AI applications.

Key Projects

Predictive Model for Medical License Resolution
This initiative aims to streamline claim assessments by determining whether licenses should be rejected or approved. Given that SUSESO receives approximately 180,000 annual claims—70% involving medical licenses—the system will leverage historical decision data from medical professionals to create predictive algorithms. Integration into administrative systems is scheduled for the first half of 2025.

Identifying Fraudulent Medical Licenses
Working with the Universidad de Chile's Industrial Engineering Department, SUSESO is developing tools to identify healthcare professionals issuing unfounded medical licenses. The system will also analyze employer complaints about license misuse and prioritize cases for prosecution referral. Completion is expected by late 2025.

Natural Language Processing for Claims
This project improves claim classification through automated text analysis of digital forms, enabling faster and more accurate routing of submissions.

Data Analytics for Oversight
A 150-million-peso initiative designed to identify operational failures and inappropriate benefit distributions, launching in phases through 2026.

Automated Document Processing
Selected under ANID's Public Challenges program, this technology extracts relevant information from digitized documents, reducing redundant data entry and accelerating claim reviews.

The total investment in these six AI projects reaches 550 million pesos, funded through competitive grants and development agencies. Full implementation is targeted for the first quarter of 2026.