Volume 23, Issue 3 (11-2024)
jhosp 2024, 23(3): 247-267 |
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Mehri M, Efatpanah M, Jaafaripooyan E, Arab M. Fraud Detection and Providing Mitigation Solutions in Iran Health Insurance Organization. jhosp 2024; 23 (3) :247-267
URL: http://jhosp.tums.ac.ir/article-1-6721-en.html
URL: http://jhosp.tums.ac.ir/article-1-6721-en.html
1- MSc, Department of Health Management, Policy & Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
2- MD & MPH, National Center for Health Insurance Research, Health Insurance Organization, Tehran, Iran.
3- PhD, Department of Health Management, Policy & Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
4- PhD, Department of Health Management, Policy & Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran. *Corresponding Author Email: arabmoha@tums.ac.ir
2- MD & MPH, National Center for Health Insurance Research, Health Insurance Organization, Tehran, Iran.
3- PhD, Department of Health Management, Policy & Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
4- PhD, Department of Health Management, Policy & Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran. *Corresponding Author Email: arabmoha@tums.ac.ir
Abstract: (27 Views)
Background and purpose: Abuse within health insurance systems represents a significant challenge for health systems globally, leading to substantial negative repercussions. This study investigates instances of abuse in the Iranian Health Insurance Organization and proposes strategies to mitigate such abuses within its primary insurance processes.
Methods: This applied study employs a qualitative methodology, with data collected via semi-structured interviews. Experts from the Iranian Health Insurance Organization were interviewed to gather their insights. Data analysis was performed using conventional content analysis, and MAXQDA 20 software was used for coding and categorizing the findings.
Results: Instances of abuse within Iran’s health insurance system were classified into two main categories: "providers" and "service recipients," which were further divided into 18 subcategories. The underlying causes of these abuses were analyzed on two levels: macro-level factors (economic, cultural-social, legal, and technological) and micro-level factors (implementation processes, oversight, and service delivery). Based on these findings, strategies for reducing abuse were proposed in three primary areas: "planning," "execution," and "control." These strategies included revising and amending relevant laws and regulations, enhancing technological infrastructure, and improving information systems in the planning phase; verifying the identities of service recipients and providers during service delivery; and strengthening oversight personnel, alongside continuous inspections, in the control phase.
Conclusion: This study indicates that revising laws and regulations within the insurance sector, upgrading technological infrastructures, providing continuous training for claims assessors, enhancing inter-organizational communication, and strengthening oversight of service providers are essential strategies for preventing abuse in the Iranian Health Insurance Organization.
Methods: This applied study employs a qualitative methodology, with data collected via semi-structured interviews. Experts from the Iranian Health Insurance Organization were interviewed to gather their insights. Data analysis was performed using conventional content analysis, and MAXQDA 20 software was used for coding and categorizing the findings.
Results: Instances of abuse within Iran’s health insurance system were classified into two main categories: "providers" and "service recipients," which were further divided into 18 subcategories. The underlying causes of these abuses were analyzed on two levels: macro-level factors (economic, cultural-social, legal, and technological) and micro-level factors (implementation processes, oversight, and service delivery). Based on these findings, strategies for reducing abuse were proposed in three primary areas: "planning," "execution," and "control." These strategies included revising and amending relevant laws and regulations, enhancing technological infrastructure, and improving information systems in the planning phase; verifying the identities of service recipients and providers during service delivery; and strengthening oversight personnel, alongside continuous inspections, in the control phase.
Conclusion: This study indicates that revising laws and regulations within the insurance sector, upgrading technological infrastructures, providing continuous training for claims assessors, enhancing inter-organizational communication, and strengthening oversight of service providers are essential strategies for preventing abuse in the Iranian Health Insurance Organization.
Type of Study: Original Article |
Subject:
سیاست گذاری ، برنامه ریزی و رهبری و مدیریت در بیمارستان
Received: 2025/02/3 | Accepted: 2025/02/19 | Published: 2025/03/12
Received: 2025/02/3 | Accepted: 2025/02/19 | Published: 2025/03/12
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