Mendeley  

Zotero  

Ramandi S, Niakan L, Rajaee Harandi S, Asheghi H. Fraud Detection in Supplementary Health Insurance and Ways to Compete. Iran J Health Insur 2020; 3 (3) :178-187
URL: http://journal.ihio.gov.ir/article-1-133-en.html

Introduction:  Fraud has direct and indirect effects on insurers and insured. Due to the nature of the insurance industry, the decisions of managers and officials will not achieve the desired result without conducting sufficient research. Therefore, this research has studied and investigated fraud in complementary health insurance and ways to deal with it through a practical approach.
Methods: In this regard, by comparative study of successful experiences of leading countries in the fight against fraud in the field of complementary health insurance and also interviews with experts in this field, processes, underlying factors and effects of fraud in complementary health insurance, obstacles and challenges in these processes was identified. Finally solutions were provided to prevent and control this phenomenon. The interviews were uploaded in text format to MAXQDA software and then analyzed.
Results: In total, 34 factors that cause fraud in the complementary health insurance industry have been identified and divided into six groups of “Rules and Regulations”, “Process Solutions”, “Technology Solutions”, and “Solutions related to institutions and organizations, “Educational Strategies” and “Cultural Strategies”. Findings showed that among the underlying factors of fraud, the most influential factor was “inefficiency of central insurance of Iran” and “ignoring the phenomenon of insurance fraud.
Conclusion: If insurance companies design and launch comprehensive and integrated systems, it will be possible to prevent a high level of fraud.