Sci Rep. 2026 Jun 12. doi: 10.1038/s41598-026-56436-2. Online ahead of print.
ABSTRACT
The management of medical insurance funds is pivotal to the development of medical consortia. These funds serve as the operational lifeline of medical consortia and constitute critical public resources essential for public welfare. Medical expense settlement involves multiple stakeholders, including patients, tiered healthcare institutions, and insurance administrative agencies. However, disputes frequently arise between medical insurance authorities and hospitals regarding expense legitimacy due to information asymmetry and interpretative discrepancies. Such conflicts impede smoothness of payment mechanism, thereby undermining consortium operations and inter-institutional collaboration. To address these challenges, this study proposes a blockchain-based framework integrating medical expense investigation with insurance settlement. The system employs two core components: Anomaly detection via the Isolation Forest (IF) algorithm to identify potentially irregular expenses. Consensus-driven adjudication using Fleiss Kappa-based smart contracts facilitated by an anonymous panel of medical experts. This design enhances coordination between expense oversight and settlement processes, thus streamlining dispute resolution for medical expense anomalies and improving the scientific governance of insurance funds. Experimentally, the statistical validity demonstrated for unsupervised anomaly detection of IF and potential engineering applicability indicated in the analysis of healthcare cost. The healthcare consortium blockchain based on a Delegated Proof-of-Stake (DPoS) consensus mechanism and smart contract batch processing achieved a peak throughput of 229.64 transactions per second (TPS) and reduced transaction costs by up to 3,095 gwei. This demonstrates scalability for real-world medical insurance collaborative settlement systems.
PMID:42286116 | DOI:10.1038/s41598-026-56436-2
