The Study Of Health Care Fraud And Abuse Control In America

With the development of economy, social health insurance mechanism isimproving and domestic medicare demand increasing. But, at the same time, thecritical problem of health insurance fraud caused unreasonable increase in heathinsurance fee, which has been severely threatening the efficiency of medicaremechanism. This tells us that combating fraud is extremely urgent. Under suchcondition, the study of foreign health care anti-fraud system, which has beensuccessfully operating, will have certain references to domestic anti-fraud work.Based on HCFAC program, this paper summarizes the history of America’s healthinsurance industry, the present situation of health insurance fraud and the presentsituatiation of health insurance anti-fraud, providing macro-background illustrations.And it details the legislations, institutional settings, financial mechanism andanti-fraud measures of HCFAC, and also analyzes the variation of health insurancefraud, the variation of HCFAC anti-fraud measures, the achievement andcharacteristics of HCFAC.What’s more, using the VRS model and Malmquist index method, it evaluates andanalyzes the technical efficiency, scale efficiency and total factor productivity ofHCFAC. The study tells us that, although HCFAC has been successfully operating, itdoes have two inadequacies: anti-fraud scale is not big enough; and anti-fraudtechniques need improving. The above study provides good references to domesticsocial health insurance anti-fraud activities.In the last part, based on HCFAC anti-fraud and efficiency analysis, this paper,according to domestic health insurance anti-fraud realities, proposes four suggestionsto domestic anti-fraud activities: expanding anti-fraud scale, gradually upgradinganti-fraud technical level，increasing transparency of medicare industry and perfectinganti-fraud environment. Hope this study can provide domestic health insuranceanti-fraud work something to learn from.