HIRA Applies AI Medical Imaging Interpretation Results to Claims Review for the First Time

Starting with Degenerative Arthritis of the Knee
Reducing Repetitive Tasks and Enhancing Review Efficiency

The Health Insurance Review and Assessment Service (HIRA) will apply artificial intelligence (AI) medical imaging analysis results—previously used only as reference materials for claims review—for the first time to its actual claims review work.

Exterior view of the Health Insurance Review and Assessment Service headquarters in Wonju, Gangwon Province. Health Insurance Review and Assessment Service

On September 1, HIRA announced that it will begin fully utilizing its claims review system powered by AI medical imaging analysis, starting with the field of knee joint disorders.

Since 2018, HIRA has developed an automated analysis system based on deep learning AI technology for interpreting medical images. By using AI analysis results for images of the spine, knee joints, and urinary tract stones as reference material during reviews, the service has accumulated relevant data and continuously advanced its interpretation models.

Going forward, HIRA will apply AI analysis results to actual claims review work starting with the field of degenerative arthritis of the knee joint, where analysis accuracy has been improved through expert validation. Claims reviewers will review AI-generated results alongside conventional review materials. If a case requires professional or medical judgment, it will be referred to a review committee. Importantly, review outcomes will not be determined solely by AI results; final decisions will always be made by human reviewers.

HIRA expects that using AI will reduce the time spent on repetitive medical image checks, thereby improving the efficiency of review work. The period required for medical institutions to confirm the outcomes of claims for medical care benefits is also expected to shorten. The service plans to redirect the time saved by automation toward reviews that require professional judgment, thereby raising both the quality and productivity of claims review.

Before deploying AI in actual review work, HIRA also established internal operational and ethical guidelines for the application of AI medical imaging analysis results, to ensure responsible AI use. The guidelines stipulate the scope and procedures of AI result utilization, and reaffirm that humans retain final decision-making authority.

HIRA plans to gradually expand the application scope to areas such as the spine and urinary tract stones, continuously assessing operational outcomes from the knee joint field and monitoring the accuracy of AI analysis.

Seungkwon Hong, president of HIRA, stated, "It is highly meaningful that AI medical imaging analysis results, which have thus far only served as reference materials, are now being applied to claims review for the first time. We will continue to actively promote AI transformation (AX) based on robust operational and ethical principles, enhancing the professionalism and efficiency of our reviews, and taking the lead in digital innovation in healthcare that the public can feel."

This content was produced with the assistance of AI translation services.