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Table 3 Macroenvironmental and Mesoenvironmental factors that influence health insurance fraud

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

Description Explanation Contribution of studies
+− + ++ − - ++
Macroenvironmental Factors
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)  
Mesoenvironmental Factors
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)   
  1. For each study, we denote with a positive sign (+) when the factor increases the HIF, and a negative sign (−) if the factor reduces the HIF; when used a single sign, it indicates that the study proved a theoretical or narrative contribution. A factor can show both signs simultaneously (+−), which means that its influence is ambivalent. In contrast, a double sign indicates that the study has an applied validation based on a method de experimentation or quasi experimentation