Understanding medical corruption in China: a mixed-methods study

Medical corruption is a significant obstacle to achieving the health-related Sustainable Development Goals. However, the understanding of medical corruption is limited, especially in developing countries. As the largest developing country, China is also plagued by medical corruption. By employing a mixed-methods design and combining data from three resources, this study attempts to examine patterns of medical corruption in China, explore its key drivers, and investigate the perceived effectiveness of recent anti-corruption interventions. Using extracted data from 3,546 cases on the China Judgments Online (CJO) website between 2013 and 2019, we found that bribery, embezzlement, and insurance fraud accounted for 68.1%, 22.8%, and 9.1% of all medical corruption cases, respectively. Bribery was the major form of medical corruption. Approximately 80% of bribe-takers were healthcare providers and most bribe-givers were suppliers of pharmaceuticals, medical equipment, and consumables. Using a nationally representative household survey, we further found that the prevalence of informal payments from patients stayed at a low level between 2011 and 2018. In 2018, only 0.4% of outpatients and 1.4% of inpatients reported that they had ever given "red envelopes" to physicians in the past. Finally, we conducted interviews with 17 key informants to explore drivers of medical corruption and investigated the perceived effectiveness of recent anti-corruption interventions in China. Interview results showed that financial pressure and weak oversight were two main reasons for corrupt behaviors. Interview results also suggested that the anti-corruption campaign since 2012, the national volume-based procurement, and the special campaign against medical insurance fraud had reduced opportunities for medical corruption, implying China's positive progress in combating medical corruption. These findings hold lessons for anti-corruption interventions in China as well as other developing countries.

Insurance Fraud in Korea, Its Seriousness, and Policy Implications

Several characteristics of insurance fraud including its chronic nature justifies the need for identifying feasible proposals which can be expected to bring about significant impacts. Recent statistics show that insurance fraud is now consistently on the increase. However, insurance fraud is highly fragmented and each offence is not significant enough to elicit active interest among the public or interventions from the police. Three problems have been identified and diagnosed. These were a lack of awareness, an absence of a national leadership and also limited attention directed to insurance fraud by the investigating authorities. Based on these, three recommendations have been suggested. (1) Embarking on and developing a national initiative by central government, (2) Taking a dynamic concentration approach to send deterrent threats to potential fraudsters, and (3) Using big data technologies to detect clandestine activities by organised groups.

FraudBuster: Reducing Fraud in an Auto Insurance Market

Nonstandard insurers suffer from a peculiar variant of fraud wherein an overwhelming majority of claims have the semblance of fraud. We show that state-of-the-art fraud detection performs poorly when deployed at underwriting. Our proposed framework "FraudBuster" represents a new paradigm in predicting segments of fraud at underwriting in an interpretable and regulation compliant manner. We show that the most actionable and generalizable profile of fraud is represented by market segments with high confidence of fraud and high loss ratio. We show how these segments can be reported in terms of their constituent policy traits, expected loss ratios, support, and confidence of fraud. Overall, our predictive models successfully identify fraud with an area under the precision-recall curve of 0.63 and an f-1 score of 0.769.

When Lying Feels the Right Thing to Do

Fraud is a pervasive and challenging problem that costs society large amounts of money. By no means all fraud is committed by 'professional criminals': much is done by ordinary people who indulge in small-scale opportunistic deception. In this paper, we set out to investigate when people behave dishonestly, for example by committing fraud, in an online context. We conducted three studies to investigate how the rejection of one's efforts, operationalized in different ways, affected the amount of cheating and information falsification. Study 1 demonstrated that people behave more dishonestly when rejected. Studies 2 and 3 were conducted in order to disentangle the confounding factors of the nature of the rejection and the financial rewards that are usually associated with dishonest behavior. It was demonstrated that rejection in general, rather than the nature of a rejection, caused people to behave more dishonestly. When a rejection was based on subjective grounds, dishonest behavior increased with approximately 10%, but this difference was not statistically significant. We subsequently measured whether dishonesty was driven by the financial loss associated with rejection, or emotional factors such as a desire for revenge. We found that rejected participants were just as dishonest when their cheating did not led to financial gain. However, they felt stronger emotions when there was no money involved. This seems to suggest that upon rejection, emotional involvement, especially a reduction in happiness, drives dishonest behavior more strongly than a rational cost-benefit analysis. These results indicate that rejection causes people to behave more dishonestly, specifically in online settings. Firms wishing to deter customers and employees from committing fraud may therefore benefit from transparency and clear policy guidelines, discouraging people to submit claims that are likely to be rejected.