IA: Understand how the INSS will detect fraud in certificates – 01/15/2024 – Market

The INSS (National Social Security Institute) began this Monday (15) testing the use of AI (artificial intelligence) to combat fraud involving social security benefits requested remotely. The institute states that, at the moment, the possibility of using AI to analyze benefits already granted is “not under study”.

As anticipated by Sheet in the Panel column, the tool, created by Dataprev (federal government technology company), will analyze the medical certificates sent by Atestmed to file a request for temporary incapacity (formerly sick pay). The objective is to cross-check data to prevent the use of false documents.

According to the president of INSS, Alessandro Stefanutto, it will be possible to identify patterns, spellings and cross-reference professional data with the CNIS (National Register of Social Information). He expects the tool to show results in 20 to 30 days.

The benefit granting process does not change. The application is made through the MeuINSS application or website, and policyholders can attach the certificate on the platform through Atestmed, which replaces medical-expert care with documentary analysis in cases of benefits lasting up to 180 days.

The artificial intelligence analysis will cross-reference data such as the doctor’s name and signature on the certificate, CRM (Regional Council of Medicine) number, the doctor’s specialty, whether the certificate presented is, in fact, where the doctor works, in addition to identifying the Computer IP, which is the unique address from which the file is sent.

Until then, the detection of fraud in the use of medical certificates in temporary disability benefit applications was manual, using a sampling system.

According to the INSS, one of the frauds being investigated by the Federal Police concerns medical certificates issued in São Paulo with four different letter patterns and the same stamp. “It was even discovered that the doctor did not work at the hospital described in the certificate and did not know that her data was being used improperly”, states the social security body, in a note.

To apply for temporary disability benefits, the insured must be insured, that is, have made at least 12 contributions to Social Security before the month of leave.

The applicant must also present a medical certificate proving the need to be away from work for more than 15 days, with a limit of 180 days. The request is via Meu INSS, using CPF and password from the Portal Gov.br.

If the INSS declares that it is not possible to grant the benefit solely through the analysis of medical or dental documents by Atestmed, it will be necessary to schedule an in-person examination. In this case, the insured will be notified via Meu INSS, through the “In-Person Expertise due to non-compliance with medical documentation” service.

The Ministry of Social Security states that the benefit will not be denied based exclusively on documentary analysis.

It is also possible to make the request via Telephone Center 135. You will need to send the medical certificate by email or deliver it to a Social Security agency.

The benefit will be granted for a period of up to 180 days, alternately or not. Insured persons who suffer an accident at work will have to present the CAT (Work Accident Report) to the INSS, otherwise they will have to schedule a medical examination.

HOW THE CERTIFICATE SHOULD BE

In order for the benefit request to be analyzed, the INSS requires that the medical certificate has been issued less than 90 days before the DER (Application Entry Date)

The medical or dental certificate must also be on paper without erasures, and contain the following information:

• Applicant’s full name
• Date of issue
• Full diagnosis or ICD code (International Classification of Diseases)
• Signature of the professional, which can be electronic and must comply with current regulations
• Identification of the doctor, with name and registration with the class council (Regional Council of Medicine or Regional Council of Dentistry), with the Ministry of Health (Ministry of Health Registry), or stamp
• Start date of rest or withdrawal from usual activities
• Time required for recovery, preferably in days (this date can be an estimate)

Forging a document is a crime. Both those who forge and those who use a false document can be sentenced to one to five years in prison and pay a fine.

Anyone who uses false documents to receive social security benefits will also have to return the entire amount received.

INSS HAS USED ARTIFICIAL INTELLIGENCE FOR 20 YEARS

The use of artificial intelligence at the INSS began around 2008, when the institute began using technological means to identify the right to retirement based on age. At the time, the insured person who reached the minimum age and had the minimum waiting period (15 years of contribution) received a letter informing them that they could apply for retirement.

Between 2022 and 2023, the INSS increased the automatic analysis of benefits using artificial intelligence from 17% to 36%. Three out of every ten benefits under the automatic review regime are granted — or denied — by an automated system. The goal is to increase analysis automation to 50% by 2026.