Studies On Fraud Of Insured Of Social Health Insurance In China Based On Utility Theory

Social medical insurance, which is to protect people’s right of seeking medicaltreatment, constantly faces fraud risks conducted by insureds as the result of moralhazard. Utility maximization restrains insureds’ rational fraudulent behavior. Thispaper intends to build a reasonable utility model to analyse insureds fraudulentconduct and give rationalizational recommendations to domestic social medicalinsurance system.Utilizing utility theory and learning from health capital medium variable inhealth demand model, it is indicated that health directly affects insureds’ utility level.Medical service, as the key element of producing health capital, links medical serviceand insureds’ utility level together. Meanwhile, assuming insureds’ fraudulent conductas health care services’ excess purse, links froud and insureds’ utility level together.Further analysis tells that the ultimate goal of fraud is to enhance utility level.Therefore, health care expenditure C1,other medical commodity expenditure C2andother consumption goods(apart from medical goods) expenditureZ all influenceinsureds’ fraudulent conduct. Furthermore, fraudulent behavior is also affected byfraud cost. Then, the above influencing factors are divided into positive and negativeones. After that, this paper establishes an analysing model to analyse insureds fraudcases.By the research, it is discovered that only through increasing health inventory orother commodity consumption, can medical insureds enhance their utility. Certainactivities, such as reselling over claimed drugs, lending insured certificates to othersetc., could be regarded as insureds resell illegally acquired medical service to increasetheir own utility. Personal medical insurance account decreases insureds’ utility sinceinsureds could withdraw their accounts’ encouragement by fraud. In brief, combatingfraud should focus on two aspects: decreasing insureds’ fraud utility by perfectingmedical insurance system and increasing insureds’ fraud cost, which is to enhancenegative fraud utility.