AI Provider Authentication Using Risk-Based Fraud Scoring
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Solution Overview
Problem
Existing authentication systems are vulnerable to unauthorized access and fraud, leading to system bottlenecks and inefficiencies, and lack comprehensive verification methods for service providers, particularly in healthcare claims processing.
Innovation Solution
An AI-based system for authenticating resource systems that integrates fraud detection and mitigation measures, utilizing machine learning models to analyze multiple data sources, perform down-sampling, and generate risk scores for service providers, enabling automated document verification and recommendation of verification levels.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Reliability
If manual processing of authentication requests is implemented, then security verification can be performed, but system bottlenecks and processing delays occur
Solution Approach 1:
The patent replaces manual mechanical authentication processing with an automated machine learning-based system. The ML model analyzes provider data, performs risk assessments, and generates verification recommendations automatically, eliminating the need for manual review while maintaining security standards. This substitution resolves the contradiction by providing both security and high processing speed.
Solution Approach 2:
The system enables self-service authentication where the ML model autonomously evaluates provider requests, determines risk levels, and generates verification recommendations without human intervention. The system serves itself by automatically processing authentication requests through trained algorithms, achieving both security and efficiency simultaneously.
2Reliability
If comprehensive authentication measures are applied to all providers, then security is improved, but legitimate providers are unduly burdened
Solution Approach 1:
The patent applies different levels of authentication scrutiny to different providers based on their risk profiles. The ML model identifies high-risk providers requiring comprehensive verification while allowing low-risk legitimate providers to undergo streamlined authentication. This localized approach to security measures resolves the contradiction by tailoring verification intensity to individual provider characteristics rather than applying uniform measures to all.
Solution Approach 2:
The system performs partial authentication for low-risk providers and comprehensive authentication for high-risk providers. Rather than applying excessive verification to all providers, the ML model determines the appropriate level of scrutiny for each case, performing only the necessary amount of verification required for each provider's risk level.
3Productivity
If automated machine learning authentication is implemented, then processing efficiency is improved, but system complexity increases
Solution Approach 1:
The patent segments the authentication system into distinct functional modules: data collection, ML model processing, risk assessment, and verification recommendation generation. This modular segmentation manages system complexity by organizing the automated authentication process into manageable, independent components that can be developed, maintained, and scaled separately while maintaining high processing efficiency.
Data Source
AI summary
Systems and methods are disclosed for determining authenticity of a resource system. The method includes receiving a dataset that includes a first subset and a second subset associated with a first resource system; down-sampling the first subset but not the second subset; generating a first feature for a machine learning model based on the down-sampled first subset; generating a second feature for the machine learning model based on the second subset; generating, via input of at least one of the first feature or the second feature into the machine learning model that is trained to output a fraudulent measure, one or more data objects indicative of validating the fraudulent measure; and initiating performance of one or more prediction-based actions in response to the generating.


