scholarly journals Fraud and Abuse in the Saudi Healthcare System: A Triangulation Analysis

2020 ◽  
Vol 57 ◽  
pp. 004695802095462
Author(s):  
Wadi B. Alonazi
Keyword(s):  
Health Insurance ◽  
Healthcare System ◽  
Insurance Industry ◽  
Rejection Rate ◽  
Healthcare Services ◽  
Macro Level ◽  
Insurance Companies ◽  
Structured Interviews ◽  
Health Insurance Companies ◽  
Micro Level

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; P < .003 and −28 > 638 to −7.362; P < .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.

scholarly journals Day Surgery Development Aspects in Slovakia

2020 ◽  
Vol 31 (2) ◽  
pp. 477
Author(s):  
Beáta Gavurová ◽  
Adela Klepáková ◽  
Ladislava Ivančová
Keyword(s):  
Health Care ◽  
Health Insurance ◽  
Pilot Study ◽  
Healthcare System ◽  
Social Groups ◽  
Day Surgery ◽  
Insurance Companies ◽  
Social Sphere ◽  
The Social ◽  
Health Insurance Companies

The day surgery is a highly effective tool for providing health care which has been used in Slovakia only for the last decade. The unified system of payment for inpatient or outpatient (day care) surgeries causes the reduction of health insurance companies´ spending. Incorrectly configured and economically demotivating system of refunding is a cause of lagging behind the European average in utilization of day surgery. Without the evaluation of day surgery it is not possible to link the progress in the social sphere, which leads to the restriction of day surgery availability for some social groups and thus the subsequent stagnation of day surgery in Slovakia. This contribution presents a pilot study conducted in Slovakia and its partial findings focused on the development and trends in the implementation of day surgery in order to increase the efficiency healthcare system.

scholarly journals IT-Standards and Standardization Approaches in Healthcare

2008 ◽  
pp. 813-820 ◽  
Author(s):  
Ali Sunyaev ◽  
Jan Marco Leimeister ◽  
Andreas Schweiger ◽  
Helmut Krcmar
Keyword(s):  
Health Insurance ◽  
Information Systems ◽  
Healthcare System ◽  
Integrated Treatment ◽  
Insurance Companies ◽  
The Internet ◽  
Healthcare Information ◽  
Systems Research ◽  
Information Systems Research ◽  
Health Insurance Companies

E-health basically comprises health services and information delivered or enhanced through the Internet and related technologies (Eysenbach, 2001). The future healthcare system and its services, enabling e-health, are based on the communication between all information systems of all participants of an integrated treatment. Connecting the elements of each healthcare system (general practitioners, hospitals, health insurance companies, pharmacies, and so on)—even across national boarders—is an important issue for information systems research in healthcare. Current developments, such as upcoming or already-deployed electronic healthcare chip cards (that are to be used across Europe), show the need for Europe-wide standards and norms (Schweiger, Sunyaev, Leimeister, & Krcmar, 2007). In this article, we first outline the advantages of the standards, and then describe their main characteristics. After the introduction of communication standards, we present their comparison with the aim to support the different functions in the healthcare information systems. Subsequently, we describe the documentation standards, and discuss the goals of existing standardization approaches. Implications conclude the article.

scholarly journals An Empirical Study on the Equity Performance of China's Health Insurance Companies During the COVID-19 Pandemic—Based on Cases of Dominant Listed Companies

2021 ◽  
Vol 9 ◽  
Author(s):  
Rendao Ye ◽  
Na An ◽  
Yichen Xie ◽  
Kun Luo ◽  
Ya Lin
Keyword(s):  
Neural Network ◽  
Health Insurance ◽  
Stock Price ◽  
Short Term Memory ◽  
Insurance Industry ◽  
Back Propagation ◽  
Listed Companies ◽  
Insurance Companies ◽  
Neural Network Models ◽  
Health Insurance Companies

The health insurance industry in China is undergoing great shocks and profound impacts induced by the worldwide COVID-19 pandemic. Taking for instance the three dominant listed companies, namely, China Life Insurance, Ping An Insurance, and Pacific Insurance, this paper investigates the equity performances of China's health insurance companies during the pandemic. We firstly construct a stock price forecasting methodology using the autoregressive integrated moving average, back propagation neural network, and long short-term memory (LSTM) neural network models. We then empirically study the stock price performances of the three listed companies and find out that the LSTM model does better than the other two based on the criteria of mean absolute error and mean square error. Finally, the above-mentioned models are used to predict the stock price performances of the three companies.

scholarly journals Risk Management Indicators in Patients with Lymphoma in Colombia

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 5852-5852
Author(s):  
Paula Ramírez ◽  
Ana Milena Gil ◽  
Juan Camilo Fuentes ◽  
Claudia Lucia Sossa ◽  
Claudia Marcela Chalela ◽  
...  
Keyword(s):  
Risk Management ◽  
Health Insurance ◽  
Healthcare System ◽  
Insurance Companies ◽  
Health Providers ◽  
Management Indicators ◽  
Health Insurance Companies ◽  
Online Voting ◽  
The Impact ◽  
Consensus Report

Abstract Background: Lymphomas are the sixth most common type of cancer in adults in Colombia. According to Cuenta de Alto Costo data from health insurance companies and health providers, there were 10,928 cases (1,257 new cases reported in 2016) of lymphoma in Colombia in 2017. Consequently, it is crucial to develop an instrument to assess and monitor risk management by insurance companies and providers in adults with diagnosis of Hodgkin and non-Hodgkin lymphoma. This would eventually contribute to reduce the impact of the disease in the patients, their families, and the healthcare system. The aim of this study was to establish evidence-based risk management indicators to measure health insurance companies' and health providers' performance in risk control in patients with lymphoma in Colombia. Methods: A consensus report was conducted adapting the method "The RAND/UCLA Appropriateness Method (RAM)". First, a detailed literature review was performed to synthesize the latest evidence on the topic. Second, a list of indicators was pre-selected. Third, expert panel rated the pre-selected indicators in two rounds. During the first-round, experts answered an online questionnaire to rate each indicator from 1 to 7 using a Likert scale. The ratings were made individually with no interaction among panelists. During the second-round, panelists met and discussed each indicator and the ratings. Then, re-rated each indicator individually. Indicators with a score over 80% were considered consensus. Fourth, a panel meeting was conducted to establish final indicators. And finally, results were shared with all actors involved in the Colombian healthcare system. Results: Twenty-four insurance companies representatives, 2 government representatives, and a public advocate participated. After reviewing the literature and a panel discussion, experts pre-selected a list of 25 management indicators which then were submitted to online voting. Twenty-three indicators achieved a high score and were validated, but since the two remaining indicators only received an intermediate score, all 25 indicators were submitted to a second online voting after discussing the first-round results. During the second-round, 3 indicators that were rated "inappropriately" by the panelists due to lack of relevance or viability, were conclusively excluded. Lastly, 15 final management indicators were approved and classified in five different domains (diagnosis, staging, treatment, opportunity, and results-overall survival, relapse-free survival, and mortality) during the panel meeting. Conclusion: Risk management indicators were established by a consensus report to assess and monitor management of patients with lymphoma by insurance companies and health providers. Since management indicators can be assessed from information reported by insurance companies to Cuenta de Alto Costo group, implementing strategies to improve survival rates and health-related quality of life can have great impact decreasing the burden of the disease in the Colombian healthcare system. Disclosures No relevant conflicts of interest to declare.

scholarly journals Using Benfords Law To Detect Fraud In The Insurance Industry

2011 ◽  
Vol 1 (7) ◽  
Author(s):  
Meredith Maher ◽  
Michael Akers
Keyword(s):  
Health Insurance ◽  
Oil And Gas ◽  
Insurance Industry ◽  
Insurance Companies ◽  
Benford’S Law ◽  
Benford's Law ◽  
Health Insurance Companies ◽  
Logarithmic Frequency ◽  
Health Insurance Industry ◽  
Fraudulent Activity

Benford's Law is the mathematical phenomena that states that the first digits or left most digits in a list of numbers will occur with an expected logarithmic frequency. While this method has been used in industries such as oil and gas and manufacturing to identify fraudulent activity, it has not been applied to the health insurance industry. Since health insurance companies process a large number of claims each year and these claims are susceptible to fraud, the use of this method in this industry is appropriate. This paper examines the application of Benford's Law to four health insurance companies located in the Midwest. For each company, analysis was performed on the first digit distribution, the first two-digit distribution, and providers with high volumes of claims. The results show that the populations are similar to the frequencies predicted by Benfords Law. The findings also suggested possible fraudulent activity by specific providers, however, the com-panies determined that these results occurred due to abnormal billing practices and were not frau-dulent. The insurance companies that participated in this study will continue to use this method to further detect fraudulent claims.

scholarly journals Which health-related reasons lead to prehospital emergency care and how does subjective emergency status connect to subsequent care?

2021 ◽  
Author(s):  
Silke Piedmont ◽  
Anna Katharina Reinhold ◽  
Jens-Oliver Bock ◽  
Enno Swart ◽  
Bernt-Peter Robra
Keyword(s):  
Health Insurance ◽  
Emergency Care ◽  
Third Party ◽  
Insurance Companies ◽  
Prehospital Emergency Care ◽  
Health Related ◽  
Life Threatening ◽  
Prehospital Emergency ◽  
Health Insurance Companies ◽  
Reported Data

Abstract Objectives/Background In many countries, the use of emergency medical services (EMS) increases steadily each year. At the same time, the percentage of life-threatening complaints decreases. To redesign the system, an assessment and consideration of the patients’ perspectives is helpful. Methods We conducted a paper-based survey of German EMS patients who had at least one case of prehospital emergency care in 2016. Four health insurance companies sent out the questionnaire to 1312 insured persons. We linked the self-reported data of 254 respondents to corresponding claims data provided by their health insurance companies. The analysis focuses a.) how strongly patients tend to call EMS for themselves and others given different health-related scenarios, b.) self-perceived health complaints in their own index case of prehospital emergency care and c.) subjective emergency status in combination with so-called “objective” characteristics of subsequent EMS and inpatient care. We report principal diagnoses of (1) respondents, (2) 57,240 EMS users who are not part of the survey and (3) all 20,063,689 inpatients in German hospitals. Diagnoses for group 1 and 2 only cover the inpatient stay that started on the day of the last EMS use in 2016. Results According to the survey, the threshold to call an ambulance is lower for someone else than for oneself. In 89% of all cases during their own EMS use, a third party called the ambulance. The most common, self-reported complaints were pain (38%), problems with heart and circulation (32%), and loss of consciousness (17%). The majority of respondents indicated that their EMS use was due to an emergency (89%). We could detect no or only weak associations between patients’ subjective urgency and different items for objective care. Conclusion Dispatchers can possibly optimize or reduce the disposition of EMS staff and vehicles if they spoke directly to the patients more often. Nonetheless, there is need for further research on how strongly the patients’ perceived urgency may affect the disposition, rapidness of the service and transport targets.

scholarly journals Health Insurance as a Healthcare Financing Mechanism in India: Key Strategic Insights and a Business Model Perspective

2021 ◽  
pp. 025609092110270
Author(s):  
Rohit Kumar ◽  
Aditya Duggirala
Keyword(s):  
Health Insurance ◽  
Business Model ◽  
Critical Success Factors ◽  
Success Factors ◽  
Insurance Industry ◽  
Insurance Companies ◽  
Healthcare Financing ◽  
Strategic Choices ◽  
Critical Success ◽  
Health Insurance Industry

This study provides strategic insights and a business model perspective on health insurance as a vehicle for financing healthcare. It uses both primary (expert interview) and secondary data to investigate the overall disease burden and healthcare industry trends and track healthcare financing through the health insurance mechanism in India. To identify the critical success factors and to gain a business model perspective within the health insurance industry, telephonic and face-to-face interviews were held with 27 experts in the healthcare, insurance, and strategic management field. The study’s findings suggest that the growth of health insurance as a healthcare financing mechanism in India has been challenged continuously and impacted by multiple changes in the health insurance and healthcare industry over the last decade. One of the critical challenges faced by insurance companies is the high incurred claim ratio. We find the Indian health insurance industry to be very competitive and that the focus on critical success factors can help insurance companies gain a competitive advantage. The health insurance business model is unique, with varying configurations, and broadly comprises strategic choices and consequences. In this article, drawing from the strategic management literature on the resource-based view (RBV) and insights gained from the interviews of healthcare and health insurance experts, we highlight the six critical success factors relevant for competing in the health insurance business. We also list five strategic choices that can help health insurance companies improve their profitability and gain a sustained competitive advantage. We recommend that the insurance companies design and develop an innovative business model centred around lowering the claim ratio and simultaneously increasing the customer willingness to pay. To increase the customer willingness to pay and reduce the claim ratio, the insurance companies should focus on the six critical success factors and invest in the five strategic choices.

Searching Dimensions and Directions for Digital Innovations Within the Insurance Industry

2021 ◽  
Vol 12 (2) ◽  
pp. 63-89
Author(s):  
Heini Hyttinen ◽  
Hannu Kalevi Kivijärvi ◽  
Anssi Öörni
Keyword(s):  
Insurance Industry ◽  
Principal Component ◽  
Knowledge Synthesis ◽  
Insurance Companies ◽  
Process Automation ◽  
Structured Interviews ◽  
Organizational Capability ◽  
Pension Insurance ◽  
Digital Innovation

Discovery of digital innovations is a key organizational capability for sustaining competitive advantage. Despite its importance, discovery of digital innovations is still ill understood. In this paper, the authors seek to provide a theory-based practice for digital innovation discovery. To meet this objective, they source the theories of knowledge and knowledge combination. Data for this case study were collected through semi-structured interviews and a quantitative questionnaire from three pension insurance companies. The data were analyzed by using principal component analysis and by constructing biplots based of the results. Two significant dimensions in the digitalization needs that guide knowledge synthesis were recognized: the importance of adopting the enabler and the volume of resources needed to adopt the enabler. A closer look at the enablers revealed that the most business-critical current digital business enablers for the pension insurance industry are business process automation, online services, and big data.

scholarly journals Thriving in a changing world – opportunities and challenges for private health insurance companies

2018 ◽  
Vol 1 (2018/1) ◽  
Keyword(s):  
Health Insurance ◽  
Private Health Insurance ◽  
Health Impact ◽  
Insurance Market ◽  
Insurance Companies ◽  
Full Potential ◽  
Global Trends ◽  
Health Insurance Companies ◽  
Health Insurance Market

The health insurance market in Poland reflects global trends – such as the rising awareness of personal health impact on quality of life. As a consequence, the health insurance market has seen substantial growth during the last years, which is forecasted to continue at over 20 percent more than life or P&C insurance globally. However, private health insurance has not yet unlocked its full potential.

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