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

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 (...

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Autores principales: Villegas-Ortega, José, Bellido-Boza, Luciana, Mauricio, David
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Springer Berlin Heidelberg 2021
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8482647/
https://www.ncbi.nlm.nih.gov/pubmed/34591187
http://dx.doi.org/10.1186/s40352-021-00149-3
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author Villegas-Ortega, José
Bellido-Boza, Luciana
Mauricio, David
author_facet Villegas-Ortega, José
Bellido-Boza, Luciana
Mauricio, David
author_sort Villegas-Ortega, José
collection PubMed
description 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. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s40352-021-00149-3.
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spelling pubmed-84826472021-10-04 Fourteen years of manifestations and factors of health insurance fraud, 2006–2020: a scoping review Villegas-Ortega, José Bellido-Boza, Luciana Mauricio, David Health Justice Research Article 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. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s40352-021-00149-3. Springer Berlin Heidelberg 2021-09-30 /pmc/articles/PMC8482647/ /pubmed/34591187 http://dx.doi.org/10.1186/s40352-021-00149-3 Text en © The Author(s) 2021 https://creativecommons.org/licenses/by/4.0/Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ (https://creativecommons.org/licenses/by/4.0/) . The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/ (https://creativecommons.org/publicdomain/zero/1.0/) ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
spellingShingle Research Article
Villegas-Ortega, José
Bellido-Boza, Luciana
Mauricio, David
Fourteen years of manifestations and factors of health insurance fraud, 2006–2020: a scoping review
title Fourteen years of manifestations and factors of health insurance fraud, 2006–2020: a scoping review
title_full Fourteen years of manifestations and factors of health insurance fraud, 2006–2020: a scoping review
title_fullStr Fourteen years of manifestations and factors of health insurance fraud, 2006–2020: a scoping review
title_full_unstemmed Fourteen years of manifestations and factors of health insurance fraud, 2006–2020: a scoping review
title_short Fourteen years of manifestations and factors of health insurance fraud, 2006–2020: a scoping review
title_sort fourteen years of manifestations and factors of health insurance fraud, 2006–2020: a scoping review
topic Research Article
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8482647/
https://www.ncbi.nlm.nih.gov/pubmed/34591187
http://dx.doi.org/10.1186/s40352-021-00149-3
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