How to detect healthcare fraud? "A systematic review"

Abstract

Objective: To identify the method used in detecting fraud cases.

Methods: Articles searching by using topic-appropriate keywords and incorporated into search engines (data-based) journals Pubmed/Medline, Cochrane, Wiley, ScienceDirect, and secondary data-based Google scholar. Then data extraction is done based on inclusion criteria. The selected articles have the aim of investigating/detecting cases of fraud that have occurred in the health sector or other related sectors that support the study.

Results: The findings of the nine reviewed articles have suggested that most of the fraud perpetrators are performed by medical personnel (doctors) and providers. Many types of fraud occur such as insurance claims or medical actions that are completely unadministered nor following the procedure and duplicating claims. The methods that appropriate to be used in detecting fraud are secondary data tracking, information, and technology specialist provision.

Conclusion: Secondary data tracking is the most widely used method in fraud detection. Fraud perpetrators are ones who dominated by medical circles with fictitious claim cases. Perpetrators tend not to act themselves but in organizations with network.

Keywords: Fraud detection; Fraud method; Healthcare services.