ABO/Rh Testing, Antibody Screening, and Biometric Technology as Tools to Combat Insurance Fraud: An Example and Discussion

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

“…This situation can occur with or without the knowledge of the owner. (r) (Baltussen et al, 2006 ; Dolan & Farmer, 2016 ; Goel, 2020 ; Jator & Hughley, 2014 ; Johnson & Nagarur, 2016 ; Li et al, 2008 ; Sheffali & Deepa, 2019 ; Shin et al, 2012 ) Doctor shopping Patients seek to stock up on controlled substances or drugs. (s) (Sheffali & Deepa, 2019 ) Misrepresenting eligibility Patients can misrepresent information about themselves or their dependents to obtain medical coverage, which is not eligible.…”

“… (Kerschbamer & Sutter, 2017 ) Measures of the administrative authority The guidelines given by health care authorities influence payment for fraud and abuse, including medical records. (Jator & Hughley, 2014 ) (Tseng & Kang, 2015 ) Internal mechanisms of discipline In the organization, some mechanisms punish fraud or abuse in health services. (Myckowiak, 2009 ) Payment method and contracts An essential part of the contract between provider and financier where payment of an amount is agreed based on assuming health risk management includes fees, payment model and contracts.…”

“… (Brooks et al, 2012 ) Patient identification mechanisms Politics and identification procedures, including biometrics. (Jator & Hughley, 2014 ) Types of health professionals Health professionals are effective in controlling fraud in medical care. (Goel, 2020 ) For each study, we denote with a positive sign (+) when the factor increases the HIF, and a negative sign (−) if the factor reduces the HIF; when used a single sign, it indicates that the study proved a theoretical or narrative contribution.…”

“…The Payment method and contracts also show ambivalent results and lose their influence on the HIF. The responsibility of the provider (Kerschbamer & Sutter, 2017 ), the measures of the administrative authority (Jator & Hughley, 2014 ), and the internal mechanisms of discipline (Myckowiak, 2009 ), the performance and quality evaluation system (Kerschbamer & Sutter, 2017 ), the commercial implication (Konijn et al, 2015 ), the employability and satisfaction with his work (Brooks et al, 2012 ), patient identification mechanisms (Jator & Hughley, 2014 ); they lose their influence in favour of reducing fraud, all supported by theoretical studies. Reputation only shows ambivalent results and loses its influence.…”

Why Not Blow the Whistle on Health Care Insurance Fraud? Evidence from Jiangsu Province, China

“…[8][9][10][11][12] In a new kind of fraud known as conspiracy, insured patients collude with their physicians to co-opt profits by preparing beds for hospitalization and exchanging self-pay items for health care insurance settlement projects. [13][14][15][16] Fraud is not only a gross waste of health care resources but also severely hampers access to quality and safe care for patients with genuine needs, thus making a crackdown on it an urgent necessity. 17,18 As fraud shifts from explicit to implicit forms and takes on cross-regional and electrical characteristics, the value of whistleblowing for prevention and identification purposes has been recognized and utilized in health care anti-fraud efforts.…”