How should regulatory schemes be optimized to enhance deterrence against medical insurance fraud by enrollees? Evidence from a discrete choice experiment in China.

Medical insurance fraud (MIF) poses a substantial global financial challenge, necessitating effective regulatory strategies, especially in China, where such measures are in a critical developmental phase. This study investigates the effectiveness of various regulatory components in deterring MIF among enrollees and explores preference heterogeneity among individuals with different characteristics, utilizing a discrete choice experiment survey. Grounded in deterrence theory, our conceptual framework incorporates five attributes: intensity of economic penalties, restrictions on medical insurance benefits, deterioration of social reputation, and certainty and celerity of penalties. Employing a D-efficiency design, 24 choice sets were generated and blocked into three versions. A multistage stratified sampling method was adopted to collect data from the basic medical insurance enrollees in Shanghai. The survey was conducted from September to October 2022. The sample representativeness was further improved via the entropy balancing approach. Data from the final sample of 1034 respondents were analyzed using mixed logit models (MIXLs), incorporating interactions with individual characteristics to assess preference heterogeneity. Results reveal that escalating economic penalties, suspending insurance benefits, listing individuals as unfaithful parties, ensuring penalty certainty, and expediting enforcement significantly enhance the deterrent effect. We observed preference heterogeneity across different demographics, including age, gender, education, health status, and employment status. The study underscores the pivotal role of economic penalties in deterring MIF, while also acknowledging the significance of non-economic measures such as enforcement efficiency and social sanctions. These findings offer valuable insights for policymakers to tailor and strengthen regulatory schemes against MIF, contributing to the advancement of more effective and precise healthcare policies.

The economic impacts of social activism and corporate social responsibility on food fraud.

The study examines the relationship between the corporate social responsibility (CSR) investments of a food firm, an activist's incentive to target the firm to uncover and deter fraudulent behavior, and the firm's incentive to commit food fraud. Specifically, we develop a game theoretic model to analyze the strategic interaction between a food firm that decides whether to provide a credence food attribute and whether to misrepresent the quality of its product, and an activist who decides whether to monitor the firm and launch a campaign to uncover and remove false/misleading quality claims. We further examine the effect of CSR and the activist's presence on the level of quality the firm provides. We derive the conditions under which an activist will find it optimal to monitor the firm to uncover fraudulent quality claims and the firm will find it optimal to misrepresent its product quality. Analytical results show that the greater the firm's CSR investments, the less likely it is that the activist will find it optimal to monitor the firm, and the more likely it is that the firm will find it optimal to misrepresent its product quality. Results also show that the firm is more likely to misrepresent its product quality when its effectiveness in contesting the activist's campaign is relatively high, and more likely to actually provide a high-quality product when the cost of the credence attribute is relatively low.

Radiology quick cash? Kickbacks, compliance, and consequences.

The Anti-Kickback Statute was passed by Congress in the 1970s to reduce the overuse of government-reimbursed medical services. It attempts to eliminate fraud, abuse, and waste of medical services by outlawing the incentive of personal gain when referring patients for government-funded services. Although safe harbors were written into the law to maintain transactions beneficial to society, they require strict adherence. Anti-Kickback Statute violations are subject to the whistleblower provision of the False Claims Act, and violations can yield significant civil and criminal penalties.

Fraud within the Nigerian health system, a double threat for resilience of a health system and the response to the COVID-19 pandemic: a review.

As Nigeria battles the COVID-19 pandemic, systemic fraud within the health system may undermine the efforts to halt the devastating effect of the disease and the fight against COVID-19. Fraud is a major concern worldwide, especially in developing countries such as Nigeria, where it is widespread within the health system. The vulnerability of the Nigerian health system despite several efforts from relevant stakeholders, has consistently been underscored before the pandemic arose, raising serious concerns. These concerns include fraud, embezzlement, and mismanagement of funds, exploitation, lack of transparency in policymaking, cutting corners in procurement processes, and taking advantage of the healthcare workforce for personal benefits. Also, other involvements in the vulnerability of the Nigerian health system that are worrisome include stakeholders using the pandemic to their advantage to increase their private benefits, a short supply of vital health resources, fraudulent recruitment of the health workforce, and ineffective crisis management. This study explores fraud within the Nigerian health system, its impact and implications for health-system resilience as well as its response to the COVID-19 pandemic. Guided by agency theory, causes and impacts of fraud in the health system and its implications on the response to COVID-19 were explained. Systematic review method was employed; out of 1462 articles identified and screened dated from 1991 to 2021, sixty articles were included in the analysis and interpretation. Specific fraud interventions should focus on a weak and vulnerable health system, service delivery, high-risk institutionalized health workforce, and addressing issues of fraud within and outside the health system in order to curb the dreaded COVID-19 and its variants in Nigeria.

Lessons from Theranos - Restructuring Biomedical Innovation.

After raising more than $700 million, Elizabeth Holmes, the founder and chief executive officer of a healthcare startup once valued at $10 billion, was found guilty on four charges of defrauding investors. Founded in 2003, Theranos Inc. was a privately held corporation that aimed to disrupt the diagnostics industry with rapid, direct-to-consumer laboratory testing using only "a drop of blood" and the company's patented Nanotainer technology. By exploiting gaps in regulatory policy, Theranos brought its panel of laboratory tests to patients without pre-market review or validation from peer-reviewed scientific research. Investigations into Theranos' dubious operations and inaccurate test results exposed the failed venture which had squandered millions of dollars. Theranos affected the lives and health of patients further disrupting an already tenuous relationship between healthcare and the public - the importance of which cannot be understated in the setting of the COVID-19 pandemic. As medical systems address a national public health crisis and pervasive structural inequities, we must align stakeholder incentives between industry and academic biomedical innovation to rebuild trust with our patients.

Bayesian inference of local government audit outcomes.

The scandals in publicly listed companies have highlighted the large losses that can result from financial statement fraud and weak corporate governance. Machine learning techniques have been applied to automatically detect financial statement fraud with great success. This work presents the first application of a Bayesian inference approach to the problem of predicting the audit outcomes of financial statements of local government entities using financial ratios. Bayesian logistic regression (BLR) with automatic relevance determination (BLR-ARD) is applied to predict audit outcomes. The benefit of using BLR-ARD, instead of BLR without ARD, is that it allows one to automatically determine which input features are the most relevant for the task at hand, which is a critical aspect to consider when designing decision support systems. This work presents the first implementation of BLR-ARD trained with Separable Shadow Hamiltonian Hybrid Monte Carlo, No-U-Turn sampler, Metropolis Adjusted Langevin Algorithm and Metropolis-Hasting algorithms. Unlike the Gibbs sampling procedure that is typically employed in sampling from ARD models, in this work we jointly sample the parameters and the hyperparameters by putting a log normal prior on the hyperparameters. The analysis also shows that the repairs and maintenance as a percentage of total assets ratio, current ratio, debt to total operating revenue, net operating surplus margin and capital cost to total operating expenditure ratio are the important features when predicting local government audit outcomes using financial ratios. These results could be of use for auditors as focusing on these ratios could potentially speed up the detection of fraudulent behaviour in municipal entities, and improve the speed and quality of the overall audit.

Organized crime in the fisheries sector threatens a sustainable ocean economy.

The threat of criminal activity in the fisheries sector has concerned the international community for a number of years. In more recent times, the presence of organized crime in fisheries has come to the fore. In 2008, the United Nations General Assembly asked all states to contribute to increasing our understanding the connection between illegal fishing and transnational organized crime at sea. Policy-makers, researchers and members of civil society are increasing their knowledge of the dynamics and destructiveness of the blue shadow economy and the role of organized crime within this economy. Anecdotal, scientific and example-based evidence of the various manifestations of organized crime in fisheries, its widespread adverse impacts on economies, societies and the environment globally and its potential security consequences is now publicly available. Here we present the current state of knowledge on organized crime in the fisheries sector. We show how the many facets of organized crime in this sector, including fraud, drug trafficking and forced labour, hinder progress towards the development of a sustainable ocean economy. With reference to worldwide promising practices, we highlight practical opportunities for action to address the problem. We emphasize the need for a shared understanding of the challenge and for the implementation of intelligence-led, skills-based cooperative law enforcement action at a global level and a community-based approach for targeting organized crime in the supply chain of organized criminal networks at a local level, facilitated by legislative frameworks and increased transparency.

Excess Medical Care Spending: The Categories, Magnitude, and Opportunity Costs of Wasteful Spending in the United States.

Landmark reports from reputable sources have concluded that the United States wastes hundreds of billions of dollars every year on medical care that does not improve health outcomes. While there is widespread agreement over how wasteful medical care spending is defined, there is no consensus on its magnitude or categories. A shared understanding of the magnitude and components of the issue may aid in systematically reducing wasteful spending and creating opportunities for these funds to improve public health.To this end, we performed a review and crosswalk analysis of the literature to retrieve comprehensive estimates of wasteful medical care spending. We abstracted each source's definitions, categories of waste, and associated dollar amounts. We synthesized and reclassified waste into 6 categories: clinical inefficiencies, missed prevention opportunities, overuse, administrative waste, excessive prices, and fraud and abuse.Aggregate estimates of waste varied from $600 billion to more than $1.9 trillion per year, or roughly $1800 to $5700 per person per year. Wider recognition by public health stakeholders of the human and economic costs of medical waste has the potential to catalyze health system transformation.

Illicit financial flows and the provision of child and maternal health services in low- and middle-income countries.

BACKGROUND: Illicit financial flows (IFFs) drain domestic resources with harmful social effects, especially in countries which are too poor to mobilise the revenues required to finance the provision of essential public goods and services. In this context, this article empirically examined the association between IFFs and the provision of essential health services in low- and middle-income countries. METHODS: Firstly, a set of indicators was selected to represent the overall coverage of essential health services at the country level. Next, a linear multivariate regression model was specified and estimated for each indicator using cross-sectional data for 72 countries for the period 2008-2013. RESULTS: After controlling for other relevant factors, the main result of the regression analysis was that an annual 1 percentage point (p.p.) increase in the ratio of IFFs to total trade was associated with a 0.46 p.p. decrease in the level of family planning coverage, a 0.31 p.p. decrease in the percentage of women receiving antenatal care, and a 0.32 p.p. decrease in the level of child vaccination coverage rates. CONCLUSIONS: These findings suggest that, for the whole sample of countries considered, at least 3.9 million women and 190,000 children may not receive these basic health care interventions in the future as a consequence of a 1 p.p. increase in the ratio of IFFs to total trade. Moreover, given that family planning, reproductive health, and child immunisation are foundational components of health and long-term development in poor countries, the findings show that IFFs could be undermining the achievement of the 2030 Agenda for Sustainable Development.

Fraudster's and victims' profiles and loss predictors' hierarchy in the mental healthcare industry in the US.

BACKGROUND: Fraud- or theft-related crimes account for the highest number of crimes in the mental health industry in the US. AIM: This exploratory study aims to demonstrate a fraudster's and respective victims' profiles as well as to identify the loss predictors' hierarchy in the mental health industry in the US. MATERIALS AND METHODS: The Psychiatric Crime database and mixed-effects models are utilized for this purpose. RESULTS: A typical fraudster's profile is defined as a 53-year old male psychiatrist who victimizes one or two of the largest federal insurance programs in states with high property crime ratios. The results revealed the year and state where the fraud is prosecuted explain the largest portion of the variance in loss size. Predictably, case-specific factors also have a significant impact on the loss. Specifically, Medicaid, the existence of collusion, and fraudster's age are associated with the fraud loss. CONCLUSIONS: This study empirically justifies considering loss, due to healthcare fraud, from a multi-level perspective. Identified typical fraudster's and respective victim's profiles helped to elaborate on specific practical recommendations aimed at fraud prevention in the mental healthcare system in the US.

The influence of corruption and governance in the delivery of frontline health care services in the public sector: a scoping review of current and future prospects in low and middle-income countries of south and south-east Asia.

BACKGROUND: The dynamic intersection of a pluralistic health system, large informal sector, and poor regulatory environment have provided conditions favourable for 'corruption' in the LMICs of south and south-east Asia region. 'Corruption' works to undermine the UHC goals of achieving equity, quality, and responsiveness including financial protection, especially while delivering frontline health care services. This scoping review examines current situation regarding health sector corruption at frontlines of service delivery in this region, related policy perspectives, and alternative strategies currently being tested to address this pervasive phenomenon. METHODS: A scoping review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) was conducted, using three search engines i.e., PubMed, SCOPUS and Google Scholar. A total of 15 articles and documents on corruption and 18 on governance were selected for analysis. A PRISMA extension for Scoping Reviews (PRISMA-ScR) checklist was filled-in to complete this report. Data were extracted using a pre-designed template and analysed by 'mixed studies review' method. RESULTS: Common types of corruption like informal payments, bribery and absenteeism identified in the review have largely financial factors as the underlying cause. Poor salary and benefits, poor incentives and motivation, and poor governance have a damaging impact on health outcomes and the quality of health care services. These result in high out-of-pocket expenditure, erosion of trust in the system, and reduced service utilization. Implementing regulations remain constrained not only due to lack of institutional capacity but also political commitment. Lack of good governance encourage frontline health care providers to bend the rules of law and make centrally designed anti-corruption measures largely in-effective. Alternatively, a few bottom-up community-engaged interventions have been tested showing promising results. The challenge is to scale up the successful ones for measurable impact. CONCLUSIONS: Corruption and lack of good governance in these countries undermine the delivery of quality essential health care services in an equitable manner, make it costly for the poor and disadvantaged, and results in poor health outcomes. Traditional measures to combat corruption have largely been ineffective, necessitating the need for innovative thinking if UHC is to be achieved by 2030.

Older and wiser: age differences in susceptibility to investment fraud: the protective role of emotional intelligence.

There have been inconsistent results regarding whether older adults are more vulnerable to fraud than younger adults. The two main goals of this study were to investigate the claim that there is an age-related vulnerability to fraud and to examine whether emotional intelligence (EI) may be associated with fraud susceptibility. Participants (N = 281; 18-82 years; M = 53.4) were recruited via Amazon's Mechanical Turk and completed measures of EI, decision-making, and scam susceptibility. Participants who scored higher on "ability" EI were less susceptible to scams. The "younger" group (M = 2.50, SD = 1.06) was more susceptible to scams than the "older" group, p <.001, d = 0.56, while the "older" group (M = 4.64, SD = 1.52) reported the scams as being more risky than the "younger" group, p =.002, d = 0.37. "Older" participants were more sensitive to risk, less susceptible to persuasion, and had higher than average emotional understanding. Emotional understanding was found to be a partial mediator for age-related differences in scam susceptibility and susceptibility to persuasion.

Socioecological indicators of senior financial exploitation: an application of data science to 8,800 substantiated mistreatment cases.

Senior financial exploitation (FE) is prevalent and harmful. Its often insidious nature and co-occurrence with other forms of mistreatment make detection and substantiation challenging. A secondary data analysis of N = 8,800 Adult Protective Services substantiated senior mistreatment cases, using machine learning algorithms, was conducted to determine when pure FE versus hybrid FE was occurring. FE represented N = 2514 (29%) of the cases with 78% being pure FE. Victim suicidal ideation and threatening behaviors, injuries, drug paraphernalia, contentious relationships, caregiver stress, and burnout and victims needing assistance were most important for differentiating FE vs non-FE-related mistreatment. The inability to afford housing, medications, food, and medical care as well as victims suffering from intellectual disability disorder(s) predicted hybrid FE. This study distinguishes socioecological factors strongly associated with the presence of FE during protective service investigations. These findings support existing and new indicators of FE and could inform protective service investigation practices.

A simple and effective method to discern the true commercial Chinese cordyceps from counterfeits.

The Chinese cordyceps, a complex of the fungus Ophiocordyceps sinensis and its species-specific host insects, is also called "DongChongXiaCao" in Chinese. Habitat degradation in recent decades and excessive harvesting by humans has intensified its scarcity and increased the prices of natural populations. Some counterfeits are traded as natural Chinese cordyceps for profit, causing confusion in the marketplace. To promote the safe use of Chinese cordyceps and related products, a duplex PCR method for specifically identifying raw Chinese cordyceps and its primary products was successfully established. Chinese cordyceps could be precisely identified by detecting an internal transcribed spacer amplicon from O. sinensis and a cytochrome oxidase c subunit 1 amplicon from the host species, at a limit of detection as low as 32 pg. Eleven commercial samples were purchased and successfully tested to further verify that the developed duplex PCR method could be reliably used to identify Chinese cordyceps. It provides a new simple way to discern true commercial Chinese cordyceps from counterfeits in the marketplace. This is an important step toward achieving an authentication method for this Chinese medicine. The methodology and the developmental strategy can be used to authenticate other traditional Chinese medicinal materials.

[Financial fraud and health: a qualitative approach]. / Fraudes financieros, salud y calidad de vida: un estudio cualitativo.

During the economic crisis, developed countries have experienced financial fraud, with effects on the physical and mental health of the people affected, and on social domains. Based on the theoretical framework in literature reviews and in quantitative studies, this paper aims to obtain evidence on the effects of financial fraud on health and on the family and social environments of those affected. An intentional sample of 32 people affected by abusive and multi-currency mortgages, preferred and swap stock in Madrid was approached. In-depth interviews were conducted, and the resulting data was analysed using content analysis. Fraud-affected individuals had conditions of age, sex, educational level and occupations that possibly allowed them to accumulate economic resources throughout the course of their lives and, predictably in many cases, to take out fraudulent financial products, based on trust in the financial institutions. Financial fraud has led to the emergence of various processes of anomia and adverse health effects. The consequences on health were physical ailments (symptoms and diseases in various systems and parts of the body) and mental disorders (anxiety, depression, suicidal ideation), all affecting lifestyles, behaviour and personal and social relationships, both in affected individuals and their families. The increase in the use of medical drugs and health services serves as a final corollary to the imbalances on the affected people's health. Individuals and the Spanish society demand public health policy measures to mitigate the effects on health and the recovery of their confidence in the banking and political system.