Theoretical Analysis And Empirical Research On China's Health Insurance Fraud

Around the whole world,insurance fraud has become a main obstacle to the smooth development of health insurance industry with the continuous development of health insurance industry.In China,the health insurance fraud causes a certain degree of economic loss every year,posing a great threat to the safety of medical insurance fund.Besides,the most direct impact of spreading of insurance fraud is that it can result in distortion of insurance pricing mechanism,which eventually harms the interests of the honest insurance applicants.As for the deep influence,insurance fraud seriously violates the principle of the greatest good faith in the insurance business and erodes the basis of insurance business.However,compared with the increasing serious insurance fraud issues,most insurance institutions are still at the battle of market share,and anti-fraud has not yet become the center of their work because of the high costs and benefits of externalities of fraud identification.Compared with the wide studies on anti-fraud in international academic circles,the study of health insurance fraud in China still focuses on qualitative analysis rather than empirical research.Based on this,this paper studies Chinese health insurance systematically,trying to do empirical research on health insurance fraud identification and then putting forward pointed anti-fraud measures.This research,not only reveals the inherent characteristics of the health insurance fraud in China to a certain extent,improving the insurance institutions' ability to identify fraud risks,which is conductive to the stability of health insurance market and the implementation of medical insurance policies,but also has important reference value to our country's insurance credit construction research and anti-fraud research.Based on the statistical analysis of the literature and on-the-spot investigation,starting from the health insurance fraud,this paper divides the performance of health insurance fraud into several categories according to its occurrence time: Ill concealing and repetitive insured behavior when buying insurance policy;Loss forging and exaggerating and making insurance accident deliberately when dealing with accidents;Forging the time when claiming for compensation.In addition,from the perspective of different insurance contracts participants,this paper deeply analyzes the damage and causes of health insurance fraud.Drawing lessons from successful experience health insurance fraud and anti-fraud in Europe and the United States,this paper discusses in-depth about Chinese health insurance fraud and anti-fraud issues,and it summarizes the problems in carrying out health insurance anti-fraud work,and analyzes the enlightenment of foreign successful practices in health insurance fraud.In the theoretical research level,making use of game theory involving the static game under incomplete and complete information and relative economic theories,this paper discusses the health insurance fraud with doctor patient collusion issue as a breakthrough point.It points finding out the underlying reasons and key factors of health insurance fraud.Besides,this paper puts forward the basic ideas of health insurance anti-fraud from the perspectives of optimal insurance contract design and insurance company management.The idea includes setting the payment terms during the design process of the insurance contract according to whether the applicant have any fraud record,making the audit cost be equal to the loss caused by insurance fraud during the process of management to achieve optimal state for insurance business institutions.In the empirical analysis,from the perspective of insurance companies,this article carefully studies the health insurance claims fraud cases in recent five years(2010~2014)of an anonymous health insurance company.Using empirical analysis,this paper summarizes 27 fraud identification indicators.And it refines to 9 indicators with LOGIT regression analysis.The indicators are: Whether the applicant's age between 41 and 50 years old,whether the applicant's professional with medium risk,whether the residence is in city or in country.Insurance amount,claim amount,whether fulfill the obligation to inform in time when insurance accident occurs.The gap length between insured date and compensation date,whether applicant could provide complete information when claiming,whether the accident is unforeseen accident.On this basis,the effectiveness of BP neural network model and LOGIT-BP neural network model in identifying health insurance fraud are respectively verified.The empirical analysis results show that both the two methods are effective in health insurance fraud identification.The correct rates to identify health insurance fraud of BP neural network model and LOGIT-BP neural network model are 70% and 80% respectively,and the later obtain better effect than the former in identifying health insurance fraud.In the end,this paper puts forward suggestions of health insurance fraud respectively from the technical and legal level.The suggestions includes forming a tripartite benefit balance mechanism covering policy-holder,insurance business institutions and government agencies learning from the anti-fraud measures carried out at present at home and abroad,constructing public participation mechanism involving information sharing and industry coordination and establishing a training system of anti-fraud.