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 | ------------------------●---- | |||||||||||||||