Einflussfaktoren für betrügerisches Verhalten von Versicherungsnehmern: erste experimentelle Befunde

Lammers, Frauke; Schiller, Jörg

doi:10.1007/s12297-010-0097-z

Cited by 9 publications

(4 citation statements)

References 28 publications

(13 reference statements)

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“…Further, the capacity building shows results in favour of reducing HIF and loses influence. Likewise, the high deductibles and coinsurance, supported by an applied study, confirm the increase to the HIF (Lammers & Schiller, 2010).…”

Section: Factors Fraudsupporting

confidence: 59%

“…Another factor that positively influences HIF is the prescription, dispensing, cost and consumption of medications (Aral et al, 2012 ; Herland et al, 2018 ; Lin et al, 2008 ; Liou et al, 2008 ; Weiss et al, 2015 ). In addition, factors related to users’ perceptions of health services such as inequity, injustice (Lesch & Baker, 2013 ), high deductibles, and coinsurance (Lammers & Schiller, 2010 ) can condition the HIF. Regarding the attitudes of claims adjusters, their decision is fickle, and has been demonstrated experimentally ambiguous (Tseng & Kang, 2015 ).…”

Section: Resultsmentioning

confidence: 99%

“…Both are out-of-pocket payments and depend on the health insurance plan contract. (Lammers & Schiller, 2010 ) Bad economic situation A bad economic situation generates financial pressure, which can cause fraud. (Ribeiro et al, 2020 ) Collaborative factors Relationship between the health professional and the patient The familiarity that exists between the health professional and the patient can influence fraud and abuse.…”

Section: Resultsmentioning

confidence: 99%

“…In the microenvironment, in the high-quality category, no applied studies have demonstrated an influence that reduces HIF. While the factors related to having an older age to be deceived (> 65), place of residence (Goel, 2020 ), patient diagnoses, medical and surgical treatments (Liou et al, 2008 ), medications (Aral et al, 2012 ; Herland et al, 2018 ; Lin et al, 2008 ; Liou et al, 2008 ; Weiss et al, 2015 ), chronic health condition (Liou et al, 2008 ), and deductibles and coinsurance (Lammers & Schiller, 2010 ) showed influence in increasing the HIF. However, other theoretical studies showed that the diagnoses (Sun et al, 2020 ) and medications reduced HIF (Haddad Soleymani et al, 2018 ; Sun et al, 2020 ; Victorri-Vigneau et al, 2009 ).…”

Section: Resultsmentioning

confidence: 99%

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Fourteen years of manifestations and factors of health insurance fraud, 2006–2020: a scoping review

2021

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Background Healthcare fraud entails great financial and human losses; however, there is no consensus regarding its definition, nor is there an inventory of its manifestations and factors. The objective is to identify the definition, manifestations and factors that influence health insurance fraud (HIF). Methods A scoping review on health insurance fraud published between 2006 and 2020 was conducted in ACM, EconPapers, PubMed, ScienceDirect, Scopus, Springer and WoS. Results Sixty-seven studies were included, from which we identified 6 definitions, 22 manifestations (13 by the medical provider, 7 by the beneficiary and, 2 by the insurance company) and 47 factors (6 macroenvironmental, 15 mesoenvironmental, 20 microenvironmental, and 6 combined) associated with health insurance fraud. We recognized the elements of fraud and its dependence on the legal framework and health coverage. From this analysis, we propose the following definition: “Health insurance fraud is an act of deception or intentional misrepresentation to obtain illegal benefits concerning the coverage provided by a health insurance company”. Among the most relevant manifestations perpetuated by the provider are phantom billing, falsification of documents, and overutilization of services; the subscribers are identity fraud, misrepresentation of coverage and alteration of documents; and those perpetrated by the insurance company are false declarations of benefits and falsification of reimbursements. Of the 47 factors, 25 showed an experimental influence, including three in the macroenvironment: culture, regulations, and geography; five in the mesoenvironment: characteristics of provider, management policy, reputation, professional role and auditing; 12 in the microenvironment: sex, race, condition of insurance, language, treatments, chronic disease, future risk of disease, medications, morale, inequity, coinsurance, and the decisions of the claims-adjusters; and five combined factors: the relationships between beneficiary-provider, provider-insurance company, beneficiary-insurance company, managers and guānxi. Conclusions The multifactorial nature of HIF and the characteristics of its manifestations depend on its definition; Identifying the influence of the factors will support subsequent attempts to combat HIF.

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Section: Factors Fraudsupporting

confidence: 59%