Skip to main content

Table 1 Definitions of health insurance fraud

From: Fourteen years of manifestations and factors of health insurance fraud, 2006–2020: a scoping review

Definition Studies Key elements identifieda
A B C D E
Deception or intentional misrepresentation that the person or entity makes knowing that the misrepresentation could result in an unauthorized benefit for the person, entity, or another part. (NHCAA, 2018) X X X   
Criminal act as a violation of civil law according to the law. Behaviours are ranging from intentional misrepresentation of services provided to inadequate documentation for Medicare/Medicaid. (Gasquoine & Jordan, 2009) X X   X X
Abuse of the system of a for-profit organization without necessarily having direct legal consequences, while prescription fraud is defined as the illegal acquisition of prescription drugs for personal use or profit and could be observed in many ways. (Aral et al., 2012)    X   X
Deception or intentional misrepresentation used to obtain illegal benefits. (Joudaki et al., 2015) X X X   
A severe federal crime and includes filing claims with the intention of “defrauding”. (Dolan & Farmer, 2016) X X   X  
Any activity with malicious intent resulting in personal benefit. (Sheffali & Deepa, 2019) X X X   
Total 6 5 5 4 2 2
  1. a Key elements identified:
  2. A. Deception or misrepresentation/Behaviours
  3. B. Intentional
  4. C. Unauthorized benefit/for-profit/personal benefit
  5. D. Criminal act according to the law/serious federal crime
  6. E. Health insurance/System abuse