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

Abstract

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.