School of Economics and Management, Shanghai University of Political Science and Law, Shanghai, China.
School of Economics and Management, Shanghai Polytechnic University, Shanghai, China.
Front Public Health. 2023 Sep 14;11:1199912. doi: 10.3389/fpubh.2023.1199912. eCollection 2023.
Combating health insurance fraud is of utmost importance to physicians, patients, and health insurers. To delve into the mechanisms of health insurance fraud between doctors and patients, this study employed evolutionary game theory to construct a model that comprehensively considers moral hazard, fraud cost, reward, punishment, bribes from patients, and other factors. Through theoretical analysis and numerical simulation of the model, the study discovered that the evolution of governance behavior in health insurance fraud is closely linked to its initial construction of the payment matrix and the initial selection of parameters for the payment matrix. Additionally, increasing penalties for fraudulent behavior, increasing the cost of fraud for both doctors and patients, and reducing moral hazard for both can effectively drive the final strategy of the system toward a non-fraudulent state. The study aims to provide valuable insights and recommendations to doctors, patients, and medical insurance institutions in establishing a sound governance environment for managing fraud behavior in health insurance.
打击医疗保险欺诈对于医生、患者和医疗保险机构来说至关重要。为深入研究医患之间医疗保险欺诈的机制，本研究运用演化博弈理论构建了一个综合考虑道德风险、欺诈成本、奖励、惩罚、患者贿赂等因素的模型。通过对模型的理论分析和数值模拟，研究发现医疗保险欺诈治理行为的演化与其支付矩阵的初始构建以及支付矩阵参数的初始选择密切相关。此外，增加欺诈行为的处罚力度、增加医患双方的欺诈成本、降低双方的道德风险都可以有效地促使系统的最终策略向非欺诈状态发展。本研究旨在为医生、患者和医疗保险机构提供有价值的见解和建议，以建立一个健全的治理环境，管理医疗保险中的欺诈行为。
