Title: Health consumer susceptibility to medical care fraud: an exploratory analysis

Authors: Michael Manocchia; Alyssa Scott; Morgan C. Wang

Addresses: CIGNA HealthCare, 900 Cottage Grove Road, Bloomfield, CT 06002, USA; Department of Sociology and Anthropology, University of North Florida, Room 2304, Building 51, 1 UNF Drive, Jacksonville, FL 32224-2659, USA. ' Blue Cross Blue Shield of Florida, 4800 Deerwood Campus Parkway, Bld. 300, Jacksonville, FL 32246, USA. ' Department of Statistics, University of Central Florida, Orlando, FL 32816-2370, USA

Abstract: Healthcare fraud and abuse by medical providers is a form of white-collar crime that has had considerable cost and consequences to society. The following study seeks to investigate factors associated with consumers that make them susceptible to potential fraud and abuse schemes. The analysis consists of 56,441 health consumers identified through Blue Cross and Blue Shield Association (BCBSA) fraud algorithms for high cost patients, billing after hour procedures and using modifiers in claims payments. The logistic regression results for any fraud event show that those who reside in the south region of Florida [odds ratio (OR) 2.39, (2.33-2.44)], are Caucasian [OR 2.07, (2.02-2.11)], with a preference sensitive condition (like hip, knee or back problems) [OR 1.76, (1.73-1.80)], who speak English [OR 1.47, (1.45-1.50)], with a higher average future risk score [OR 1.29, (1.28-1.30)], are female [OR 1.16, (1.14-1.18)] and have HMO insurance [OR 1.14, (1.11-1.18)] were more likely to have encountered potential fraud during 2008.

Keywords: healthcare fraud; white-collar crime; consumer awareness; medical care fraud; abuse algorithms; medical providers; healthcare providers.

DOI: 10.1504/IJPP.2012.045878

International Journal of Public Policy, 2012 Vol.8 No.1/2/3, pp.136 - 148

Published online: 31 Jul 2014 *

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