Abstract
BackgroundHealthcare 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).MethodsA scoping review on health insurance fraud published between 2006 and 2020 was conducted in ACM, EconPapers, PubMed, ScienceDirect, Scopus, Springer and WoS.ResultsSixty-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.ConclusionsThe 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.
Highlights
Healthcare fraud entails great financial and human losses; there is no consensus regarding its definition, nor is there an inventory of its manifestations and factors
Once the possible studies had been chosen, the two authors read the full text, which allowed us to select those that contribute directly to the research questions (Theoretical Fraud, Practical Manifestation, Factors), and we identified them in the matrix; the authors reached at a consensus
We excluded 24 studies related to health insurance fraud (HIF) detection techniques, data mining models, processes, activities or other aspects not related to the factors and manifestations of HIF
Summary
Healthcare fraud entails great financial and human losses; 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). Corruption and fraud are embedded in health systems (HS), and they are motivated by abuse of power and dishonesty (García, 2019) that harm the user population, generating economic and even human losses (World Bank, 2018). There is a constant increase in healthcare spending, healthcare professionals seeking to maximize their profits, and health insurance seeking to contain costs (Dumitru et al, 2011; Wan & Shasky, 2012)
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