Publication: Preventing, Detecting, and Deterring Fraud in Social Health Insurance Programs: Lessons from Selected Countries
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Date
2018-11
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2018-11
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This paper draws lessons from anti-fraud experiences in social health insurance programs of six selected countries across the income spectrum: Indonesia, the Philippines, Republic of Korea, Croatia, Turkey, and the United States. A standardized questionnaire was used to collect information on how the programs prevent, detect, and deter fraud. The questionnaire was supplemented by a literature review and conversations with key informants. The analysis summarizes similarities and differences in the legal framework, institutional mechanisms, and capacity to manage fraud. Across all countries, the primary responsibility for managing fraud lies with the public entity that administers the program. In terms of capacity, all program-administering agencies have dedicated anti-fraud units and staff. In addition, all countries have specific anti-fraud policies and guidelines that address fraud and have a clear operational and legal definition of fraud. In terms of preventing fraud, the use of pre-authorization screening for high-end procedures is common. For detecting fraud, most countries use anti-fraud ‘hotlines’ and encourage other forms of reporting of suspected fraudulent behavior; the use of ‘red flags’-triggers that identify suspicious claims based on deviations from norms, is also common. The level of sophistication in using data analytics to detect potential fraud, however, varies across countries. Social health insurance programs in higher-income countries are more likely to use advanced statistical and data-mining techniques compared to those in lower-income countries. All programs across all countries undertake post-reimbursement medical claims and beneficiary audits. In terms of deterring fraud, sanctions often include the use of financial penalties, cancellation of contracts, and criminal prosecutions; however, in most countries, public providers are not penalized and prosecuted to the same degree as private providers.
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“Chabra, Sheena; Menon, Rekha; Postolovska, Iryna; Smith, Owen; Tandon, Ajay; Ulep, Val. 2018. Preventing, Detecting, and Deterring Fraud in Social Health Insurance Programs: Lessons from Selected Countries. Health, Nutrition and Population Discussion Paper;. © World Bank. http://hdl.handle.net/10986/31013 License: CC BY 3.0 IGO.”
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