Research on the Formation Path and Prevention Strategies of Medical Insurance Fraud from the Perspective of Configuration
Mao Qian
Li Chunbo
Zhan Changchun
Zhou Lülin
Abstract：Objective:To explore the mechanism that leads to the formation of medical insurance fraud,in order to propose countermeasures and suggestions for preventing medical insurance fraud.Methods:Taking 30 provinces and cities in China as research objects,Fuzzy-Set Qualitative Comparative Analysis and Necessary Condition Analysis are applied to explore the configuration paths that lead to medical insurance fraud.Results:A single factor does not constitute a necessary condition for a high incidence of Medicare insurance fraud.There are four grouping paths that lead to a high incidence of Medicare insurance fraud,namely,the dominant factor of poor medical insurance operation status,the dual auxiliary factor of low informationization level and weak regulatory mechanism under the dominant status of poor medical insurance operation,the auxiliary pathway of low economic level under the dual dominance factors of poor medical insurance operation and low informationization level,and the three dominant factors of poor medical insurance operation as well as weak regulatory mechanism and low economic level.Conclusion:Medical insurance fraud is caused by multiple factors,therefore the following prevention strategies are proposed,focusing on rectifying and breaking through difficult problems,strengthening regulatory effectiveness through departmental linkage,enhancing regulatory accuracy through technological empowerment,and improving long-term mechanisms by addressing both symptoms and root causes.
Keywords：social medical insurancemedical insurance fraudprevention strategyFuzzy-Set Qualitative Comparative AnalysisNecessary Condition Analysis
Publication Date：2025-03-05
Online Publishing Date：2025-08-15(First online date of this platform, not the publication date of the document)
Pages：6( 37-42 )