Fraud in the health systems of Chile: a detection model

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dc.contributor.authorMesa, Francisco R.
dc.contributor.authorRaineri, Andres
dc.contributor.authorMaturana, Sergio
dc.contributor.authorMaria Kaempffer, Ana
dc.date.accessioned2024-01-10T12:05:34Z
dc.date.available2024-01-10T12:05:34Z
dc.date.issued2009
dc.description.abstractObjectives. To develop a model for detecting cases of organized fraud in Chile based on data from the legal forms for medically authorized leave (formulario legal de licencia medica curativa-MAL) and to establish the relevance of this data to fraud detection.
dc.description.abstractMethods. A binomial logistic regression model was employed using four variables from the MAL form, a national requirement for illness-related work absences: the number of legal absences taken by a single person, the number of days authorized by the prescribing doctor, the total cost per illness, and a dichotic variable reflecting whether or not the diagnosis is one that can be proven. The analysis involved 4 079 MAL forms that had been submitted in 2003 to a private health provider and of which 356 were already identified as fraudulent by a panel of medical fraud experts.
dc.description.abstractResults. The model successfully identified 99.71% of the fraudulent medical authorizations and 99.86% of the non-fraudulent, according to the criteria of the panel of fraud experts. Three of the variables employed had statistically-significant independent predictive power. The positive predictive value of the proposed model was 98.59%, while its negative predictive value was 99.97%.
dc.description.abstractConclusions. The binomial logistic model that was developed uses four variables that are common to all MAL forms in use by Chile's public as well as private insurers, permitting separation of fraudulent from non-fraudulent requests to be more accurate, more timely, and at a cost lower that of an expert panel.
dc.fechaingreso.objetodigital2024-06-25
dc.format.extent6 páginas
dc.fuente.origenWOS
dc.identifier.issn1020-4989
dc.identifier.pubmedidMEDLINE:19341525
dc.identifier.wosidWOS:000264531800009
dc.information.autorucIngeniería;Maturana S;S/I;61254
dc.information.autorucEscuela de Administración;Raineri A;S/I;57223
dc.issue.numero1
dc.language.isoes
dc.nota.accesoContenido completo
dc.pagina.final61
dc.pagina.inicio56
dc.publisherPAN AMER HEALTH ORGANIZATION
dc.revistaREVISTA PANAMERICANA DE SALUD PUBLICA-PAN AMERICAN JOURNAL OF PUBLIC HEALTH
dc.rightsacceso abierto
dc.subjectFraud
dc.subjectinsurance
dc.subjecthealth
dc.subjectdecision support techniques
dc.subjectChile
dc.subject.ods03 Good Health and Well-being
dc.subject.odspa03 Salud y bienestar
dc.titleFraud in the health systems of Chile: a detection model
dc.typeartículo
dc.volumen25
sipa.codpersvinculados61254
sipa.codpersvinculados57223
sipa.indexWOS
sipa.indexScopus
sipa.trazabilidadCarga SIPA;09-01-2024
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