Health Administration Department, King Saud University, Riyadh, Saudi Arabia.
Inquiry. 2020 Jan-Dec;57:46958020954624. doi: 10.1177/0046958020954624.
In the insurance industry, the majority of fraud and abuse cases fall into a limited number of patterns, yet false claims normally lead to negative national, local, and organizational effects. Through monitoring the exploitative and abusive behavior commonly found in healthcare services, this paper aims to analyze initiatives implemented by governmental and related healthcare insurance agencies in Saudi Arabia to reduce moral offenses. To accomplish this objective, major governmental health insurance policy documents were analyzed at the macro-level. At the meso-level, semi-structured interviews were conducted with five health insurance professionals on measures undertaken to prevent such incidents. At the micro-level, the critical factors of fraudulent behaviors were analyzed using a retrospective analysis. Data were retrieved from anti-fraud records of ten leading health insurance companies and the focus was mainly on individuals involved in unethical practices between 2014 and 2019. After a full audit was completed, the results concluded that the Saudi healthcare system is composed of twenty-six cooperative health insurance agencies and over 5,202 health services providers. The official documents contain the details of various moral hazard measures. On annual average, more than 196 fraudulent cases were reported with a claim rejection rate of approximately 15%. The majority of fraud cases were reported in dental services with invalid card usage, followed by obstetrics-gynecology services (47 and 113 cases, respectively). Females tended to make up most deceit cases in obstetrics-gynecology with a high level of abuse (95% confidence interval: -83.398 to -24.202; < .003 and -28 > 638 to -7.362; < .005, respectively). This study ultimately identifies basic measures employed at the macro-level to reduce moral hazards. However, such measures are not intended to be coherently implemented at the micro-level, especially by health insurance companies and healthcare providers.
在保险行业，大多数欺诈和滥用案件都属于有限的几种模式，但虚假索赔通常会导致国家、地方和组织的负面后果。本文通过监测医疗服务中常见的剥削和滥用行为，旨在分析沙特阿拉伯政府和相关医疗保险机构为减少道德违规行为而实施的举措。为了实现这一目标，对宏观层面的主要政府医疗保险政策文件进行了分析。在中观层面，对五名医疗保险专业人员进行了半结构化访谈，了解他们为防止此类事件而采取的措施。在微观层面，使用回顾性分析方法分析了欺诈行为的关键因素。数据来自十家领先的医疗保险公司的反欺诈记录，重点是 2014 年至 2019 年期间涉及不道德行为的个人。完成全面审计后，结果表明沙特的医疗保健系统由 26 家合作医疗保险机构和 5202 多家医疗服务提供商组成。官方文件包含各种道德风险措施的详细信息。平均每年报告超过 196 起欺诈案件，拒付率约为 15%。大多数欺诈案件发生在牙科服务中，涉及无效卡使用，其次是妇产科服务（分别为 47 起和 113 起）。在妇产科中，女性往往构成大多数欺骗案例，滥用程度较高（95%置信区间：-83.398 至 -24.202；<0.003 和-28 > 638 至-7.362；<0.005）。本研究最终确定了在宏观层面减少道德风险的基本措施。然而，这些措施并非旨在微观层面上一致实施，尤其是在医疗保险公司和医疗服务提供者方面。
