How to detect healthcare fraud? “A systematic review”

Thaifur, Andi Yaumil Bay R.; Maidin, M. Alimin; Sidin, Andi Indahwaty; Razak, Amran

doi:10.1016/j.gaceta.2021.07.022

Cited by 15 publications

(10 citation statements)

References 13 publications

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“…For instance, Yang and Hwang ( 15 ) proposes a data-mining framework that utilizes the concept of clinical pathways to facilitate automatic and systematic construction of an adaptable and extensible detection model. Thaifur et al ( 16 ) uses the gaming theory to analyze the conditions and processes of the gaming between the hospital insured and the Urban Workers' Basic Medical Insurance organization and revealed the causes and existent necessity of the moral hazard. Sparrow and Malcolm ( 17 ) investigates whether there are any differences in public attitudes toward fraud committed against the public agencies vs. the private insurance companies.…”

Section: Literature Reviewmentioning

confidence: 99%

Research on the Formation Mechanism of Health Insurance Fraud in China: From the Perspective of the Tripartite Evolutionary Game

Fei

Yang

et al. 2022

Front. Public Health

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The problem of fraud in China's health insurance has existed for a long time and is becoming more serious, which needs to be solved urgently. This article constructs a tripartite evolutionary game model to study the formation mechanism of the Health Insurance fraud, game participants including medical administrative organization (MAO, a government department responsible for health insurance supervision), medical institutions (MI, such as hospitals), and insured individuals (II, who participating in medical and healthcare insurance). By analyzing the equilibrium of the tripartite evolutionary game, this paper makes an in-depth study on the formation and resolution of health insurance fraud. The results show that: (1) How to prevent the fraud behavior of the medical institutions is the difficulty and core of the problem. It is necessary to achieve effective supervision of the MAO, improve the internal management of the MI and give play to the supervisory role of the II. (2) The regulatory behavior of the MAO needs to focus on protecting the interests of the II, not only to encourage them to actively play the role of supervision and reporting but also to prevent their collusion with MI. (3) On the one hand, the MAO needs to strengthen supervision and increase the punishment for fraud. On the other hand, they also need to take incentive measures to guide all subjects to form a sound internal management mechanism.

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Section: Literature Reviewmentioning

confidence: 99%

Research on the Formation Mechanism of Health Insurance Fraud in China: From the Perspective of the Tripartite Evolutionary Game

Fei

Yang

et al. 2022

Front. Public Health

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“…Health insurance fraud can take various forms, including the submission of false claims, duplicate claims, and fraudulent billing for services that are not provided [ 40 ]. Insurance companies strive to detect and mitigate fraud, but their success can be hindered by legal and organizational obstacles.…”

Section: Discussionmentioning

confidence: 99%

Exploring the Challenges in Covering Dental Services through Complementary Insurance in Iran: A Qualitative Study

Pouraskari,

Yazdani,

Hessari

2024

International Journal of Dentistry

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Background. Financial protection is crucial for attaining universal health coverage. The inclusion of costly dental services in insurance plans poses a significant challenge for all parties involved in the insurance sector. This study aimed to investigate the challenges of covering dental services by complementary insurance in Iran during 2020–2021. Materials and Methods. This qualitative research was conducted in Iran during 2020–2021. A triangulation of methods and data sources were employed to achieve a comprehensive perspective. In-depth semistructured interviews were conducted on an individual basis, and all national documents, rules, regulations, and instructions pertaining to complementary dental insurance were thoroughly reviewed. Purposeful sampling was used to select participants from all stakeholder groups engaged in dental insurance coverage, including (1) health system policymakers, (2) insurers, (3) policyholders, (4) care providers (dentists), and (5) insured people. Six open-ended questions were formulated to explore various facets of dental insurance, including (1) development, (2) management, (3) population coverage, (4) premium calculation, (5) services coverage, and (6) payment and reimbursement mechanisms. With the consent of the participants, all interviews were recorded and transcribed verbatim. The gathered data were evaluated using a framework analysis approach in the MAXQDA20 software. Finally, the primary themes, each encompassing multiple subthemes, were identified and presented. Results. A total of 26 interviews were conducted with five groups of interviewees, and nine national documents were evaluated. Six themes were extracted, which included 18 codes from the interviews and seven codes from the documents. The extracted themes were as follows: (1) Insurance commitments and service coverage, (2) reimbursement system, (3) information system, (4) economic issues, (5) population coverage, and (6) regulation and supervision. The high cost of dental services was the most frequent challenge, followed by the insurance commitments and service coverage. Conclusions. The delivery of dental services through complementary insurance in Iran primarily faces economic and service coverage challenges. The resolution hinges on the collaboration between basic and complementary insurance sectors, the development of a unified information system for insured individuals, and the implementation of a risk-adjusted premium plan.

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“…Stiernstedt ( 13 ) proposed to establish an international private health insurance sector in preventing fraud and providing healthcare services. Thaifur ( 14 ) used game theory to analyze the conditions and processes of the game between medical institutions and basic medical insurance organizations, and reveal the causes and the necessity of the existence of moral hazard. In fraud risk identification, the emphasis is mainly on the application of data mining and neural network techniques.…”

Section: Introductionmentioning

confidence: 99%

Research on the risk governance of fraudulent reimbursement of patient consultation fees

Sun,

Wang,

Zhang

et al. 2024

Front. Public Health

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BackgroundThe fundamental medical insurance fund, often referred to as the public’s “life-saving fund,” plays a crucial role in both individual well-being and the pursuit of social justice. Medicare fraudulent claims reduce “life-saving money” to “Tang’s monk meat”, undermining social justice and affecting social stability.MethodsWe utilized crawler technology to gather textual data from 215 cases involving fraudulent health insurance claims. Simultaneously, statistical data spanning 2018 to 2021 was collected from the official websites of the China Medical Insurance Bureau and Anhui Medical Insurance Bureau. The collected data underwent comprehensive analysis through Excel, SPSS 26.0 and R4.2.1. Differential Auto-Regressive Moving Average Model (ARIMA (p, d, q)) was used to fit the fund safety forecast model, and test the predictive validity of the forecast model on the fund security data from July 2021 to October 2023 (the fund security data of Anhui Province from September 2021 to October 2023).ResultsThe outcomes revealed that fraudulent claims by health insurance stakeholders adversely impact the equity of health insurance funds. Furthermore, the risk management practices of Medicare fund administrators influence the publication of fraudulent claims cases. Notably, differences among Medicare stakeholders were observed in the prevalence of fraudulent claims. Additionally, effective governance of fraudulent claims risks was found to have a positive impact on the overall health of healthcare funds. Moreover, the predictive validity of the forecast model on the national and Anhui province’s fund security data was 92.86% and 100% respectively.ConclusionWe propose four recommendations for the governance of health insurance fraudulent claims risk behaviors. These recommendations include strategies such as “combatting health insurance fraudulent claims to preserve the fairness of health insurance funds”, “introducing initiatives for fraud risk governance and strengthening awareness of the rule of law”, “focusing on designated medical institutions and establishing a robust long-term regulatory system”, and “adapting to contemporary needs while maintaining a focus on long-term regulation”.

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How to detect healthcare fraud? “A systematic review”

Cited by 15 publications

References 13 publications

Research on the Formation Mechanism of Health Insurance Fraud in China: From the Perspective of the Tripartite Evolutionary Game

Research on the Formation Mechanism of Health Insurance Fraud in China: From the Perspective of the Tripartite Evolutionary Game

Exploring the Challenges in Covering Dental Services through Complementary Insurance in Iran: A Qualitative Study

Research on the risk governance of fraudulent reimbursement of patient consultation fees

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