Preventing, Detecting, and Deterring Fraud in Social Health Insurance Programs
This paper draws lessons from anti-fraud experiences in social health insurance programs of six selected countries across the income spectrum: Indonesia, the Philippines, Republic of Korea, Croatia, Turkey, and the United States. A standardized questionnaire was used to collect information on how the programs prevent, detect, and deter fraud. The questionnaire was supplemented by a literature review and conversations with key informants. The analysis summarizes similarities and differences in the legal framework, institutional mechanisms, and capacity to manage fraud. Across all countries, the primary responsibility for managing fraud lies with the public entity that administers the program. In terms of capacity, all program-administering agencies have dedicated anti-fraud units and staff. In addition, all countries have specific anti-fraud policies and guidelines that address fraud and have a clear operational and legal definition of fraud. In terms of preventing fraud, the use of pre-authorization screening for high-end procedures is common. For detecting fraud, most countries use anti-fraud ‘hotlines’ and encourage other forms of reporting of suspected fraudulent behavior; the use of ‘red flags’-triggers that identify suspicious claims based on deviations from norms, is also common. The level of sophistication in using data analytics to detect potential fraud, however, varies across countries. Social health insurance programs in higher-income countries are more likely to use advanced statistical and data-mining techniques compared to those in lower-income countries. All programs across all countries undertake post-reimbursement medical claims and beneficiary audits. In terms of deterring fraud, sanctions often include the use of financial penalties, cancellation of contracts, and criminal prosecutions; however, in most countries, public providers are not penalized and prosecuted to the same degree as private providers.
| Main Authors: | , , , , , |
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| Format: | Working Paper biblioteca |
| Language: | English |
| Published: |
World Bank, Washington, DC
2018-11
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| Subjects: | SOCIAL HEALTH INSURANCE, FRAUD, ADMINISTRATIVE PROCEDURES, CIVIL SERVICE REFORM, HEALTH SERVICE DELIVERY, |
| Online Access: | http://documents.worldbank.org/curated/en/204671543466503538/Preventing-Detecting-and-Deterring-Fraud-in-Social-Health-Insurance-Programs-Lessons-from-Selected-Countries https://hdl.handle.net/10986/31013 |
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| Summary: | This paper draws lessons from anti-fraud
experiences in social health insurance programs of six
selected countries across the income spectrum: Indonesia,
the Philippines, Republic of Korea, Croatia, Turkey, and the
United States. A standardized questionnaire was used to
collect information on how the programs prevent, detect, and
deter fraud. The questionnaire was supplemented by a
literature review and conversations with key informants. The
analysis summarizes similarities and differences in the
legal framework, institutional mechanisms, and capacity to
manage fraud. Across all countries, the primary
responsibility for managing fraud lies with the public
entity that administers the program. In terms of capacity,
all program-administering agencies have dedicated anti-fraud
units and staff. In addition, all countries have specific
anti-fraud policies and guidelines that address fraud and
have a clear operational and legal definition of fraud. In
terms of preventing fraud, the use of pre-authorization
screening for high-end procedures is common. For detecting
fraud, most countries use anti-fraud ‘hotlines’ and
encourage other forms of reporting of suspected fraudulent
behavior; the use of ‘red flags’-triggers that identify
suspicious claims based on deviations from norms, is also
common. The level of sophistication in using data analytics
to detect potential fraud, however, varies across countries.
Social health insurance programs in higher-income countries
are more likely to use advanced statistical and data-mining
techniques compared to those in lower-income countries. All
programs across all countries undertake post-reimbursement
medical claims and beneficiary audits. In terms of deterring
fraud, sanctions often include the use of financial
penalties, cancellation of contracts, and criminal
prosecutions; however, in most countries, public providers
are not penalized and prosecuted to the same degree as
private providers. |
|---|