ArticlePloS one2025
Research on quantitative evaluation of medical insurance fraud supervision policy based on 'Antecedents-Process-Outcomes' framework.
Article in PloS one, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 3 papers, 1 of them a synthesis that pooled it.
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Who cites it
3 citing papers in PubMed, 1 synthesis or guideline pooled it.
- Economic impact of health insurance fraud, waste, and abuse: a literature review of direct and indirect costs and system sustainability.Frontiers in public health · 2026Pooled it
- Does the reform of equalization of basic public services affect residents' sense of safety?-A case from China.Frontiers in public health · 2026Article
- What goals does China's medical insurance fund supervision aim to achieve? A quantitative analysis based on national-level policies.BMC health services research · 2025Article
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Authors and funding
4 authors.
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No grant is acknowledged in the PubMed record.
Abstract
Fraud in medical insurance is a serious problem that threatens the safety and sustainability of medical insurance funds. The process of reducing or even eliminating the impact of fraud is related to maintaining the balance of payments for medical insurance funds and reforming the payment system based on total amount control. As a result of reviewing the policy background of medical insurance fraud in China, combined with the policy evaluation model in the area of public management, this paper develops a conceptual framework of 'Antecedents-Process-Outcomes' that emphasizes the fraud and governance of medical insurance funds. This paper uses grounded theory to look at 180 cases of medical insurance fraud and then uses the PMC index model to rate 18 policies. It then looks at the joint progressive analysis framework of medical insurance fraud and fraud supervision. In this paper, we analyze the policy similarities and differences of medical insurance fraud supervision in China from three perspectives: policy attributes, policy contents, and policy effects. The average PMC index of the 18 policies is 4.98, which is generally acceptable; however, there are some deficiencies in the policy field, policy supervision chain, policy orientation, and policy tools. Then, it puts forward suggestions for improving the four policy shortcomings in order to provide theoretical and practical enlightenment for the high-quality development of the medical security system and realize the new medical security in the process of Chinese-style modernization.
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Registered trials
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