Study of Provider Perceptions of Types and Extent of Fraud in Health Insurance and Factors Influencing Ethics in Healthcare Provisioning: Learnings from the World’s Largest Public Health Insurance Scheme in India

Provider malpractices under health insurance programmes are common and have far-reaching implications for financial losses to health-financing agencies and may result in an adverse impact on patient healthcare and trust. The characteristics of the health insurance market make the health insurance market extremely susceptible to fraud. Current information on healthcare fraud has mostly emanated from high-income countries which have vastly different healthcare systems as opposed to lower-middle income countries. We conducted a perception-based cross-sectional study of healthcare providers across five Indian states which have implemented the Prime Minister Jan Arogya Yojana health insurance scheme, the largest public-funded health insurance in the world covering 500 million individuals across the country. The study presents provider perceptions of various frauds and underlying causes, based on the theory of planned behaviour. Proactive actions by the state around the detection and investigation of fraud are more effective in the deterrence of malpractices as compared to reactive measures pertaining to disciplinary actions and punishments post the fraud has occurred. Delay in provider reimbursements by the state impacts provider revenues as the cost of care has already incurred. This in turn may provide a rationalisation to providers to resort to malpractices to recover the unpaid money which is due to them. Paper-based medical records can be easily manipulated by providers; hence, the adoption of electronic health records would limit providers’ capability to commit fraud. The level of fraud in the state was found to be strongly associated with the actions of the state. Proactive actions by the state such as investigation and audit were found to be more effective in reducing fraud than reactive measures such as disciplinary actions. Timely payments and leveraging electronic health records were also found to be significant.