The Chilean Superintendency of Social Security (SUSESO) is implementing a data-driven strategy to address the growing issue of fraudulent medical leave certificates. This plan leverages artificial intelligence (AI) to detect suspicious patterns in the issuance of these certificates, enabling the identification of professionals, employers, and workers potentially involved in fraud before these activities become widespread. The approach aims not only to prevent future cases but also to optimize investigations and effectively penalize those responsible.
The model under development includes advanced analytical tools that help prioritize investigations, focusing on cases with a higher likelihood of lacking medical justification. This involves early alerts and the possibility of referring cases to the Public Prosecutor's Office for legal action. Expected outcomes include improved efficiency in inspections and a reduction in instances of abuse within the medical leave system.
The issue stems from organized networks operating via social media to issue fraudulent medical certificates for profit. These networks have inflicted significant economic harm on the state and private insurers, estimated at hundreds of billions of pesos. Notable cases have involved foreign doctors leading these operations, accumulating illicit gains that include properties and luxury goods.
In parallel, Congress is discussing legal reforms to strengthen regulations and penalties related to medical leave certificates. These reforms propose stricter requirements for issuers, enhanced tools for oversight institutions like COMPIN and ISAPRES, and harsher penalties for fraudulent activities. Additionally, there are efforts to create public registries of sanctioned doctors and expedite the use of national medical exams as a prerequisite for issuing medical certificates.
Source: df.cl
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