中国健康保险欺诈的理论分析与实证研究
[Abstract]:In the world, with the continuous development of health insurance industry, insurance fraud has become the main obstacle to the smooth development of health insurance industry. In China, health insurance fraud has caused a certain degree of economic loss every year, which poses a great threat to the safety of medical insurance fund. And the most direct effect of insurance fraud is the most direct effect of insurance fraud. The risk pricing mechanism is distorted and ultimately damages the interests of the honest insured. In the deep influence, insurance fraud will seriously damage the maximum honesty principle of insurance operation and erode the contract basis of insurance operation. However, most insurance institutions are still in the battle of market share, and the fraud knowledge is still in the competition of market share compared with the increasingly serious insurance fraud. The externality of high cost and income makes anti fraud not a central task. Moreover, compared with the international academic circle of anti fraud research, the study of health insurance fraud in China is mainly focused on qualitative analysis and few empirical studies. Based on this, this paper intends to systematically study the health insurance fraud in China, and Try and open the empirical research work of health insurance fraud identification, and then put forward targeted anti fraud measures. Through this study, we can not only reveal the inherent characteristics and laws of health insurance fraud in our country to a certain extent, improve the ability and level of the insurance institutions to identify fraud risks and anti fraud, and be beneficial to the health insurance market. The stability and the implementation of the medical insurance policy also have an important reference value to the research on the construction of insurance integrity and the research on anti fraud in China. Based on the statistical analysis and field investigation of the documents, the concept of health insurance fraud is defined and the forms of health insurance fraud are entered according to the time of fraud. On the basis of the inductive analysis, the malicious insure insurance and the repeated insurance behavior when buying the policy, the forgery loss, exaggeration, expansion of the loss and the intentional manufacture of insurance accident, the forgery time behavior of the claim, and the harm caused by the health insurance fraud from the angle of the different insurance contracts involved in the owner. With the successful experience of health insurance fraud and anti fraud in European and American countries, the problems of health insurance fraud and anti fraud in China are deeply analyzed, and the problems existing in China's health insurance anti fraud work are summarized and summarized, and the success of foreign health insurance anti fraud is analyzed and studied. At the theoretical level, the theoretical method of static game of complete information static game and incomplete information is used, and the typical health insurance fraud of doctor and patient conspiracy is taken as an example. From the point of view of game analysis, the deep reasons of health insurance fraud and the key factors that cause fraud are analyzed. From the angle of optimal insurance contract design and the management and management of insurance companies, the basic idea of health insurance anti fraud is given. In the course of the design of insurance contract, the difference clause should be set up according to the insured person without fraud. The audit cost of the claim case is equal to the loss caused by insurance fraud. On the empirical analysis level, from the perspective of the insurance company, the characteristics of the suspected fraud cases of several insurance companies' health insurance claims are combed, and the comprehensive health insurance of the XX insurance company in five years 2010~2014 is taken as an example, and the experience analysis method is used to sum up the 27. A fraud identification index, and then the use of LOGIT regression analysis to refine the identification of fraud indicators to 9, that is, whether the age of the insured is between the age of 41~50, whether the occupation is a medium risk occupation, whether the residence is a county, the size of the insured amount, the amount of the claim amount, and whether the timely notification obligation is fulfilled when the insurance accident is insured and the date of insurance and the date of the insurance. The difference between the date and time is long, and can the claim be complete and whether the type of accident is an accident. On this basis, the validity of the BP neural network model and the LOGIT-BP neural network model to the identification of health insurance fraud is verified. The results of the empirical analysis show that these two methods are all identified by health insurance fraud. Effective methods, the correct rates of identifying health insurance fraud by using BP neural network model and LOGIT-BP neural network model are 70% and 80% respectively. In addition, the LOGIT-BP neural network model can obtain better recognition results than BP neural network model. Finally, the health insurance anti fraud is given from the technical and legal aspects. The countermeasures are to draw on and integrate the anti fraud measures currently implemented in the field of health insurance at home and abroad, and to discuss the establishment of the balance mechanism for the three parties covering the insured, the insurance business and the government management institutions, and discussing the policy suggestions of establishing the information sharing, the industry coordination, the anti fraud participation mechanism of the public and the anti fraud training system.
【学位授予单位】:青岛大学
【学位级别】:博士
【学位授予年份】:2015
【分类号】:D924.35;F842.6
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