A Novel Multi-view Bi-clustering method for identifying abnormal Co-occurrence medical visit behaviors

Guo, Yubing; Zheng, Zhihua; Kong, Lanju; Guo, Wei; Zhou, Yan; Cui, Lizhen; Wang, And Xiao-Fang

doi:10.1016/j.ymeth.2022.09.004

Cited by 5 publications

(2 citation statements)

References 21 publications

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“…Wu Haibo (2014) criticized the dual role of the government in managing and executing medical insurance funds, highlighting the resulting high pressure, low e ciency, and inadequate supervision under the current "o cial establishment, o cial management, and o cial supervision" model [5] . Finally, Fan et al (2020) identi ed the core paths of hospital fraud, attributing them to individuals, organizations, systems, and policies through a rigorous process of literature coding, analysis, comparison, classi cation, and integration [6] .The fraud methods in the special medical insurance sector have also undergone a transformation, evolving from explicit to increasingly covert forms [7] .…”

Section: Introductionmentioning

confidence: 99%

Identification of Critical Paths for Medicare fraud -- Configuration Analysis Based on Fraud Triangle Theory

Wang

2024

Preprint

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Purpose The primary objective of this study is to address the urgent need to eliminate medical insurance fraud in the regulation of healthcare funds. Given the increasingly complex nature of fraud perpetrators, their methods, and the underlying motives, the supervision of medical insurance funds faces significant challenges.Methods To achieve this objective, we adopt a multi-faceted approach. Firstly, we draw upon the fraud triangle theory and insurance contract-related theories to establish an analytical framework. Secondly, we employ fuzzy-set qualitative comparative analysis (fs/QCA) to conduct a configurational analysis of medical insurance fraud cases from 31 provinces (including municipalities and autonomous regions) published by China's National Medical Insurance Administration.Results Our analysis reveals three primary pathways of medical insurance fraud: the "triangle-supported" type,the "pressure-driven" type, and the "opportunity-exploiting" type. Notably, the "pressure-driven" type emerges as the most prominent fraud pathway in China. Furthermore, private institutions are identified as high-risk areas for fraudulent activities compared to other entities.Conclusion In conclusion, this study offers valuable insights into the diverse and evolving nature of medical insurance fraud in China. By leveraging the fraud triangle theory and fs/QCA, we identify key fraud pathways and highlight the significant role of private institutions in perpetrating these fraudulent acts. The findings inform targeted strategies to strengthen the regulation of medical insurance funds and mitigate the risks associated with fraud.

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Section: Introductionmentioning

confidence: 99%

Identification of Critical Paths for Medicare fraud -- Configuration Analysis Based on Fraud Triangle Theory

Wang

2024

Preprint

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“…As the number of medical insurance fraud incidents continues to increase [ 8 , 9 ], fraudulent methods continue to shift from the explicit to the implicit, and fraudulent behavior continues to evolve and remain hidden [ 10 ], posing new challenges to the supervision of medical insurance funds. Whistleblowing is the most common and effective method of detecting fraud [ 11 ].…”

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confidence: 99%

What are people’s attitudes toward medical insurance fraud whistleblowers? a study from China

Chen,

Deng,

et al. 2024

BMC Public Health

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Purpose Medical insurance fraud has caused huge losses to countries around the world, and public reporting has become an important means to combat medical insurance fraud. The attitude of medical insurance fraud whistleblowers affects people’s reporting behavior, and understanding people’s attitude toward medical insurance fraud whistleblowers provides a basis for further improving the system and policy of public participation in medical insurance fund supervision. Methods We adopted the questionnaire method to conduct a national cross-sectional survey of the Chinese public and analyzed the data using Chi-square tests, Fisher’s exact tests, and binary logistic regression models. Results A total of 837 respondents were included, and 81.8% of the population had a supportive attitude toward medical insurance fraud whistleblowers, with gender, whether they had used medical insurance reimbursement, and present life satisfaction being statistically significant (P < 0.05). Conclusion The public is generally supportive of medical insurance fraud whistleblowers, and women, those who have used medical insurance for reimbursement, and those who are satisfied with their lives are more likely to be supportive of medical insurance fraud whistleblowers.

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A Decision Tree and Logistic Regression Algorithm-Based Model for Predicting Crimes Committed by Health Insurance Fraudsters

Yuan,

Li,

Sun

et al. 2023

Lecture Notes on Data Engineering and Communications Technologies

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A Novel Multi-view Bi-clustering method for identifying abnormal Co-occurrence medical visit behaviors

Cited by 5 publications

References 21 publications

Identification of Critical Paths for Medicare fraud -- Configuration Analysis Based on Fraud Triangle Theory

Identification of Critical Paths for Medicare fraud -- Configuration Analysis Based on Fraud Triangle Theory

What are people’s attitudes toward medical insurance fraud whistleblowers? a study from China

A Decision Tree and Logistic Regression Algorithm-Based Model for Predicting Crimes Committed by Health Insurance Fraudsters

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