Research on the Formation Path and Prevention Strategies of Medical Insurance Fraud from the Perspective of Configuration
- VernacularTitle:组态视角下医保欺诈形成路径及防范策略研究
- Author:
Qian MAO
1
;
Chunbo LI
;
Changchun ZHAN
;
Lülin ZHOU
Author Information
1. 江苏大学管理学院 江苏 镇江 212013;南京大学商学院 江苏 南京 201093
- Publication Type:Journal Article
- Keywords:
social medical insurance;
medical insurance fraud;
prevention strategy;
Fuzzy-Set Qualitative Comparative Analysis;
Necessary Condition Analysis
- From:
Chinese Health Economics
2025;44(3):37-42
- CountryChina
- Language:Chinese
-
Abstract:
Objective:To explore the mechanism that leads to the formation of medical insurance fraud,in order to propose countermeasures and suggestions for preventing medical insurance fraud.Methods:Taking 30 provinces and cities in China as research objects,Fuzzy-Set Qualitative Comparative Analysis and Necessary Condition Analysis are applied to explore the configuration paths that lead to medical insurance fraud.Results:A single factor does not constitute a necessary condition for a high incidence of Medicare insurance fraud.There are four grouping paths that lead to a high incidence of Medicare insurance fraud,namely,the dominant factor of poor medical insurance operation status,the dual auxiliary factor of low informationization level and weak regulatory mechanism under the dominant status of poor medical insurance operation,the auxiliary pathway of low economic level under the dual dominance factors of poor medical insurance operation and low informationization level,and the three dominant factors of poor medical insurance operation as well as weak regulatory mechanism and low economic level.Conclusion:Medical insurance fraud is caused by multiple factors,therefore the following prevention strategies are proposed,focusing on rectifying and breaking through difficult problems,strengthening regulatory effectiveness through departmental linkage,enhancing regulatory accuracy through technological empowerment,and improving long-term mechanisms by addressing both symptoms and root causes.
