Fraud in healthcare facilities: A Narrative Review

Abstract

Every country needs to develop Universal Health Coverage (UHC) to promote optimal levels of public health. But in realizing UHC, there must be some problems, one of which is fraud. Based on the Corruption Eradication Commission (KPK) data, potential fraud is detected from 175,774 claims of Advanced Referral Health Facilities (FKRTL) or worth Rp. 440 billion until June 2015. This review article describes the incidence of fraud in health care facilities. Out of a total of 12,736 cases of fraud, readmission occupies the most cases of fraud, which is 4,827 cases or 37.9%.

Towards a Secure Technology-Driven Architecture for Smart Health Insurance Systems: An Empirical Study

“…The insurance claim will be validated by 𝓗 𝓹 with the help of patient input data 𝚰 𝝆 , the obtained treatment 𝓣 𝓸 , and through the data stored on 𝓗 𝓬 , that will yield the result of legitimate HIN claims 𝓛 𝓲 by identifying and reporting 𝓕 𝓬 , as shown in Equation (8).…”

“…The insurance claim will be validated by 𝓗 𝓹 with the help of patient input data 𝚰 𝝆 , the obtained treatment 𝓣 𝓸 , and through the data stored on 𝓗 𝓬 , that will yield the result of legitimate HIN claims 𝓛 𝓲 by identifying and reporting 𝓕 𝓬 , as shown in Equation (8). For efficient ℘ , the transmission of 𝚰 at maximum speed 𝑺(𝒙) and minimum latency 𝓛(𝒙) is required, which is only possible if 𝓖 is implemented and working properly, as shown in Equation (5).…”

“…The insurance claim will be validated by 𝓗 𝓹 with the help of patient input data 𝚰 𝝆 , the obtained treatment 𝓣 𝓸 , and through the data stored on 𝓗 𝓬 , that will yield the result of legitimate HIN claims 𝓛 𝓲 by identifying and reporting 𝓕 𝓬 , as shown in Equation (8). C needs to be stored on the healthcare cloud H using G, and the corresponding hash value will be added to the new block of the blockchain B where the machine learning algorithm will be applied to extract legitimate HIN claim L .…”

“…ρ , the obtained treatment T ℴ ℴ ℴ , and through the data stored on H , that will yield the result of legitimate HIN claims L by identifying and reporting F , as shown in Equation (8).…”

“…People without HIN delay necessary treatment and depend more heavily on hospital emergency rooms, diverting limited resources to address diseases that might often have been averted or treated in a lower-cost environment. The absence of HIN has severe cost consequences for people, communities, and the health care system [ 6 , 7 , 8 ].…”