Holistic Approach to Fraud Management in Health Insurance
نویسندگان
چکیده
Fraud presents an immense problem for health insurance companies and the only way to fight fraud, is by using specialized fraud management systems. Current research community has focused great efforts on different fraud detection techniques, while neglecting other also important activities of fraud management. We propose a holistic approach that focuses on all 6 activities of fraud management, namely, (1) deterrence, (2) prevention, (3) detection, (4) investigation, (5) sanction and redress, and (6) monitoring. The main contribution of the paper are 15 key characteristics of a fraud management system, which enable effective and efficient support to all fraud management activities. We base our research on literature review, interviews with experts from different fields, and a case study. The case study provides additional confirmation to expert opinions, as it puts our holistic framework into practice.
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