Social Health Insurance Fraud Behavior Research

The effective operation of social medical insuranceis an important social security guarantee for the life and development of human,and is closely related to the harmony and stability of social society.In the development process of medical insurance industry,the medical insurance fund is facing more and more risk.Some criminals colluded with the insured clients,defrauded the medical fund by buying drugs from other people's insurance card,buying more or unnecessary drugs,and selling to the illegal drug traders later.Some medical institutions and their staff violate the regulation of medical insurance,and commit the medical fraud to take medical fund by selling drugs and providing illusive medical service,resulting in significant economic loss.At present,medical insurance fraud(MIF)and other illegal issues have become a social problem,which is related to the safety of medical insurance fund,becoming a stumbling block to the healthy development of medical insurance industry.Firstly,this paper summarizes the current research status at home and abroad and research ideas,interprets the background of MIF theoretically,analyzes the current medical insurance status in China and characteristics of medical insurance in Shanghai,and summarizes the types of MIF and anti-fraud means.On the basis of public policy,public economics,and political science,this paper uses the research methods,such as literature research,case study,survey research,grounded theory,and data mining,makes data collection and empirical analysis on the fraud data from Shanghai Medical Insurance Supervision Institute in the viewpoint of both fraud behavior analysis and features of violated clients.Based on the deep analysis of three cases of MIF by illegal buying and selling drugs,the data are analyzed by statistical methods such as data mining and regression analysis.The reasons for the occurrence of MIF are explained,and data characteristics of various types of MIF are qualitatively studied.The data model of MIF is established based on the characteristics of MIF,and the forecast identification factor of MIF is put forward,providing reference for how to choose the suspicious clients from the behavior characteristics.Finally,the insurance fraudster's behavior patterns are analyzed and summarized combining the MIF's status and antifraud measures in Shanghai medical insurance industry,and the causes and policy loopholes of MIF are also explored,making suggestion for improving anti-fraud work.This paper provides a reference for the study of social MIF,for how to plan the system design of anti-fraud work,and for how to improve the anti-fraud management of medical insurance.