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Table 5 Studies that identify factors according to their quality assessment

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

  Quality of Studies
High [11–13] Medium[7–10] Low[4–6]
Factors Contributions of studies +− + ++ − - ++ +− + ++ − - ++ +− + ++ − -
Macroenvironmental Factors
1. Norms and regulations ----------------------------   ---------------------------- ---------------------------- --------------------  
2. Economic, political and social conditions ----------------------------   ----------------------------   ----------------------------  
3. Infrastructure      ----------------------------  
4. Culture    ---------------------------- ---------------------------- ----------------------------  
5. The complexity of health systems      --------------------------  
6. Geography ----------------------------    ----------------------------   
Mesoenvironmental Factors
7. General characteristics of the provider -------------------------- ----------------------     
8. Responsibility of the provider      ----------------------------  
9. Measures of the administrative authority ----------------------------     ----------------------------  
10. Internal mechanisms of discipline      ----------------------------  
11. Payment method and contracts ------------------------      
12. The medical record    ----------------------------   --------------------------  
13. Audit, supervision, sanction and control -------------------------- ---------------------------- ----------------------------   ----------------------  
14. Performance and quality evaluation system      ----------------------------  
15. Reputation   ----------------------------    ----------------------------  
16. Commercial implication ----------------------------      
17. Lacks of Complaints management and policy ---------------------------- ----------------------------   ----------------------------   
18. Reimbursement processes and billing characteristics --------------------------     ----------------------------  
19. Employability and job satisfaction      ----------------------------  
20. Patient identification mechanisms      ----------------------------  
21. Types of health professionals (nurse)   ----------------------------     
Microenvironmental Factors
22. Sex ----------------------------   ---------------------------- --------------------------   
23. Age   ---------------------------- -------------------------- ----------------------------   
24. Predominant race     ----------------------------   
25. Marital status    ----------------------------    
26. Place of residence ---------------------------- ---------------------------- ----------------------------    
27. They have insured status     ----------------------------   
28. Predominant language     ----------------------------   
29. Diagnostics -------------------------- ---------------------- ----------------------------    
30. Medical and surgical treatments ---------------------------- ----------------------------   ----------------------------   ------------------
31. Specialities -------------------------- --------------------------     
32. Medications -------------------- ------------------     
33. Chronic health condition   ----------------------------   ----------------------------   
34. Future risk of illness     ----------------------------   
35. Ethics and morals --------------------------   ---------------------- -------------------------- ------------------------  
36. Perception of inequity and injustice    ---------------------------- ----------------------------   
37. Information asymmetry    ------------------------   ----------------------------  
38. The decision of the adjusters   ----------------------------     
39. Strengthening of capacities      ----------------------------  
40. Deductibles and coinsurance   ----------------------------     
41. Economic situation    ----------------------------    
Collaborative factors
42. Relationship between the health professional and the patient --------------------------      
43. The complicity between the provider and the insurer ---------------------------- ----------------------------     
44. Relationship between the consumer and the provider -------------------------- ----------------------------     
45. Relationship between the consumer and the insurer     --------------------------   
46. The influence of bosses   ----------------------------     
47. The guānxi between insurance salespeople and customers     ----------------------------   
  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