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首页> 美国卫生研究院文献>Inquiry: A Journal of Medical Care Organization Provision and Financing >Fraud and Abuse in the Saudi Healthcare System: A Triangulation Analysis
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Fraud and Abuse in the Saudi Healthcare System: A Triangulation Analysis

机译：沙特医疗保健系统中的欺诈和虐待：三角测量分析

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In the insurance industry, the majority of fraud and abuse cases fall into a limited number of patterns, yet false claims normally lead to negative national, local, and organizational effects. Through monitoring the exploitative and abusive behavior commonly found in healthcare services, this paper aims to analyze initiatives implemented by governmental and related healthcare insurance agencies in Saudi Arabia to reduce moral offenses. To accomplish this objective, major governmental health insurance policy documents were analyzed at the macro-level. At the meso-level, semi-structured interviews were conducted with five health insurance professionals on measures undertaken to prevent such incidents. At the micro-level, the critical factors of fraudulent behaviors were analyzed using a retrospective analysis. Data were retrieved from anti-fraud records of ten leading health insurance companies and the focus was mainly on individuals involved in unethical practices between 2014 and 2019. After a full audit was completed, the results concluded that the Saudi healthcare system is composed of twenty-six cooperative health insurance agencies and over 5,202 health services providers. The official documents contain the details of various moral hazard measures. On annual average, more than 196 fraudulent cases were reported with a claim rejection rate of approximately 15%. The majority of fraud cases were reported in dental services with invalid card usage, followed by obstetrics-gynecology services (47 and 113 cases, respectively). Females tended to make up most deceit cases in obstetrics-gynecology with a high level of abuse (95% confidence interval: −83.398 to −24.202; P < .003 and −28 > 638 to −7.362; P < .005, respectively). This study ultimately identifies basic measures employed at the macro-level to reduce moral hazards. However, such measures are not intended to be coherently implemented at the micro-level, especially by health insurance companies and healthcare providers.
机译：在保险业中，大多数欺诈和虐待案件属于有限数量的模式，但虚假主张通常导致负国家，地方和组织效应。通过监测医疗保健服务中常见的剥削和虐待行为，本文旨在分析沙特阿拉伯政府和相关医疗保险机构实施的举措，以减少道德犯罪。为实现这一目标，在宏观层面分析了主要的政府健康保险单文件。在中学级别，半结构化访谈由五个健康保险专业人员进行，以防止此类事件进行措施。在微观层面，使用回顾性分析分析了欺诈行为的关键因素。从十个领先的健康保险公司的反欺诈记录中取消了数据，重点主要是2014年和2019年之间参与不道德实践的个人。在完成全面审计后，结果得出结论，沙特医疗保健系统由二十次组成六个合作健康保险机构和5,202多名卫生服务提供商。官方文件包含各种道德风险措施的细节。根据年平均水平，报告了196份欺诈案件，索赔拒绝率约为15％。大多数欺诈案件在牙科服务中报告了无效卡使用，其次是产科 - 妇科服务（分别为47和113例）。女性倾向于在高水平的滥用水平（95％置信区间：-83.398至-24.202; p <.003和-28> 638至-7.362; p <.005分别） 。本研究最终确定了宏观水平所采用的基本措施，以减少道德危害。但是，这些措施并非旨在在微观层面上连贯地实施，特别是由健康保险公司和医疗保健提供者在微观上实施。

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