| Summary: | 碩士 === 國立中正大學 === 犯罪防治研究所 === 105 === National health insurance system has been benefited the majority of people so far, but endless health insurance fraud is one of the important factors that caused health insurance deficit by difficulties and distribution of injustice. Such cases have high hidden crime and so on, if we can’t explore the crime patterns of such crimes, and put forward specific and feasible measures for the relevant units to prevent and remove, we will not maintain and continue health insurance system in the long run. Therefore, this study attempts to achieve the following three purposes: First, to understand the criminal practices and sentencing results of health insurance fraud cases; Second, to explore the causes of health insurance fraud and summarize the relevant crime and so on; Third, to put forward to the prevention and control recommendations for National Health Insurance Administration and related units reference.
This study collected a total of 54 cases in the first instance verdict of local health insurance fraud cases from January 2007 to April 2016 in Yunlin, Chiayi and Tainan, and analyzed the results of the judgment and the types of the related crimes. In addition, we interviewed four persons of health fraud through qualitative research, to understand behavior background, economic conditions, motivations and methods, cognition of victims and health insurance damage, cognitive responsibility and so on.
We also interviewed three judicial officers who have investigated and dealt with the practical experience of health insurance fraud and three health insurance officers to understand their views on the current situation of health insurance fraud and the deterrent nature of the existing judgments on such cases. The results of the study found that health insurance fraud cases occurred in the highest rate of primary clinic, the patient is mostly informed and with the main suspect to the most physician, criminal techniques, including not the actual diagnosis and treatment of pseudo-filled medical records, for fake hospital, secret medicine, borrow pharmacist license and so on. More than 90% of the defendants can be probation or easy to fine, the perpetrators are generally dissatisfied with the current health insurance system, do not admit that they have a crime, do not think that they will cause damage to others or health insurance, its performance confirm to Techniques of Neutralization Theory and Rational Choice Theory of criminology theory.
In view of the above findings, the end of this study is divided into three aspects: institutional norms, legal system and moral education. First, the institutional norms: medical information transparency, set the report line and bonuses, see the video when the file for future reference, to avoid licensing by name; Second, the legal system: to increase the criminal punishment, to strengthen the law education of medical staff, to pursue the responsibility of the people by the card, the use of "internal conflict clause”. Third, the moral part: to strengthen the medical ethics education, promote the correct medical information, improve the public consciousness and so on, so as to reduce the probability of fraud cases.
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