A CONCEPTUAL PERFORMANCE EVALUATION FRAMEWORK FOR BLOCKCHAIN-BASED HEALTHCARE INSURANCE FRAUD PREVENTION: COMPARATIVE INSIGHTS FROM THE ABHA DIGITAL HEALTH ECOSYSTEM

Abstract

 Healthcare insurance fraud continues to impose substantial financial and operational burdens on healthcare providers, insurers, and government agencies, while undermining trust in digital health ecosystems. Although the Ayushman Bharat Health Account (ABHA) ecosystem has significantly improved health information accessibility and interoperability through standardized digital identities and consent-driven data sharing, it is not specifically designed to provide immutable, decentralized, and fraud-resistant insurance claim verification. Blockchain technology offers a promising alternative by enabling transparent transaction recording, tamper-resistant data management, automated claim validation through smart contracts, and end-to-end auditability.
This study proposes a blockchain-based framework for healthcare insurance fraud prevention and develops a multidimensional performance evaluation model to compare the proposed architecture with the ABHA digital health ecosystem. The proposed framework integrates decentralized ledger technology, cryptographic security mechanisms, smart contracts, identity verification, and audit trails to enhance the integrity and transparency of healthcare insurance claim processing. A comprehensive evaluation framework is established using eight critical performance dimensions: security, transparency, fraud detection capability, data integrity, privacy preservation, transaction efficiency, scalability, and interoperability.
The comparative methodology is designed to assess the operational strengths and limitations of both architectures within healthcare insurance workflows while maintaining interoperability and regulatory compliance.
The study contributes to the literature in three significant ways. First, it presents a dedicated blockchain-enabled framework tailored to healthcare insurance fraud prevention rather than general health record management. Second, it introduces a multidimensional benchmarking model that enables systematic comparison between blockchain-based insurance processing and the ABHA digital health ecosystem. Third, it provides a foundation for future empirical validation and policy development by identifying standardized performance indicators for secure, transparent, and trustworthy digital health insurance systems. The proposed framework offers a scalable and privacy-preserving approach that can support next-generation healthcare insurance infrastructures and facilitate the adoption of decentralized technologies for fraud-resistant claim management.