Table 3 Macroenvironmental and Mesoenvironmental factors that influence health insurance fraud

Norms and regulations

There are increasingly stricter regulations to control medical services; however, diversity also increases its complexity.

(Krause, 2013; Vian et al., 2012)

(Kose et al., 2015; Maroun & Solomon, 2014; Myckowiak, 2009; Wang, 2014)

(Ribeiro et al., 2020)

(Lesch & Baker, 2013)

Economic, political and social conditions

Economic recessions and other political conditions can condition lobbies, corruption and facilitate fraud.

(Ribeiro et al., 2020)

(Perez & Wing, 2019; Wang, 2014)

Infrastructure

New equipment and technologies make fraud methods more sophisticated and complex.

(Brooks et al., 2012)

Culture

It determines the way of acting of the population and their way of interacting conditions their behaviour.

(Ribeiro et al., 2020)

(Brooks et al., 2012)

(Zourrig et al., 2018)

The complexity of health systems

The complexity of health systems and their particularities make management, prevention and detection efforts and strategies are complicated.

(Faux et al., 2019; Vian et al., 2012)

Geography

Geographic data are helpful for the prevention and detection of fraud and abuse in health services.

(Musal, 2010)

(Manocchia et al., 2012)

General characteristics of the provider

It includes their legal nature for profit or not, location, competitiveness index, services they provide, schedules, payment statistics, history of their production.

(Bauder et al., 2017; Herland et al., 2019)

(Wan & Shasky, 2012)

(Massi et al., 2020)

(Herland et al., 2018; Kang et al., 2010)

Responsibility of the provider

If the provider maintains responsible conduct in its administrative and medical actions.

(Kerschbamer & Sutter, 2017)

Measures of the administrative authority

The guidelines given by health care authorities influence payment for fraud and abuse, including medical records.

(Jator & Hughley, 2014)

(Tseng & Kang, 2015)

Internal mechanisms of discipline

In the organization, some mechanisms punish fraud or abuse in health services.

(Myckowiak, 2009)

Payment method and contracts

An essential part of the contract between provider and financier where payment of an amount is agreed based on assuming health risk management includes fees, payment model and contracts.

(Kose et al., 2015; Park et al., 2016; Shin et al., 2012)

The medical record

The power of the medical record can improve the diligence and mastery of the documentation, which allows talking through the record without having to say a word.

(Dolan & Farmer, 2016; Smith et al., 2013)

(Gasquoine & Jordan, 2009)

Audit, supervision, sanction and control

The design of practical audit and control strategies and programmes can improve the efficiency of providing services to patients and mitigating fraud, abuse or corruption. The penalty and fear of penalty are also considered in this factor.

(Hillerman et al., 2017; Maroun & Solomon, 2014; Myckowiak, 2009; Smith et al., 2013; Vian et al., 2012)

(Bourgeon & Picard, 2014; Dionne et al., 2009)

(Kang et al., 2010)

Performance and quality evaluation system

An adequate system contributes to the quality of decision-making, feedback, dependence on employees and minimizes the possibility of fraud.

(Kerschbamer & Sutter, 2017)

Reputation

Opinion, idea or concept that people have about a health service provider.

(Kerschbamer & Sutter, 2017)

(Tseng & Kang, 2015)

Commercial implication

Medical practice is being bypassed by commercial considerations that could overlook fraud.

(Konijn et al., 2015)

Lack of complaints management and policy

The complex nature of administrative, financial and benefits management and its case-mix condition the first line of claims management.

(Lee et al., 2016)

(Lesch & Baker, 2013)

(Wan & Shasky, 2012)

Reimbursement processes and billing characteristics

The billing pattern of the providers, including the duration of medical procedures or treatment of complex medical conditions.

(Lee et al., 2016)

(Hillerman et al., 2017; Kerschbamer & Sutter, 2017)

Employability and job satisfaction

How satisfied employees are decreases staff turnover, absenteeism, motivation with their work and decrease corruption.

(Brooks et al., 2012)

Patient identification mechanisms

Politics and identification procedures, including biometrics.

(Jator & Hughley, 2014)

Types of health professionals

Health professionals are effective in controlling fraud in medical care.

(Goel, 2020)