Study on the Fraud Patterns and Claim Management of Prevention Strategies for Health Insurance

• Main Authors: Chia-Yeh Wu, 吳佳曄
• Other Authors: Miao-Hui Tseng
• Format: Others
• Language: zh-TW
• Published: 2016
• Online Access: http://ndltd.ncl.edu.tw/handle/56pffx

碩士 === 淡江大學 === 保險學系保險經營碩士在職專班 === 104 === It is difficult to count the dark figure of insurance fraud. The formation of moral hazards is highly variable for the operation of insurance companies. Should insurance fraud succeed, the insurance premiums would also increase, which is ultimately distributed amongst non-offending policyholders. Therein, commercial health insurance frauds are mostly low in claim amount but occur frequently. With the recent rise in fraud, there is now a trend towards fraud syndicates and specializations. The author has integrated their own knowledge with the practical experience of a senior medical claims officer, and made use of literature analysis and deep participation for their research method. Taiwan’s current commercial health insurance fraud is collated here and there are three proposed outcomes from this study：1. Medicare fraud are not necessarily planned in advance, rather it might occur unpremeditated.2. Medical institutions play a key role in medicare fraud.3. To prevent medicare fraud, one needs to have a deep understanding of the client’s life.Additionally, the author has proposed ways to improve the claim process from the point of view of a professional insurance claims handler, and this may be used as a point of reference by related units.