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    Title: 醫療院所參與保險詐欺之動機研究
    Other Titles: The motivation of medical institutions participation on medicare fraud
    Authors: 劉佳芬;Liu, Chia-Fen
    Contributors: 淡江大學保險學系保險經營碩士在職專班
    曾妙慧;Tseng, Miao-Hui
    Keywords: 醫療保險;地區型醫療院所;醫療霸權;白領犯罪;集團式詐欺;保險詐欺;Medicare Insurance;Regional Medical Institutions;Medical Hegemony;White-Collar Crime;Syndicated Fraud;Insurance Fraud
    Date: 2016
    Issue Date: 2017-08-24 23:36:59 (UTC+8)
    Abstract: 商業醫療保險詐欺,由於理賠金額小、但重覆性高,以致於對保險公司而言,常以一種蠶食的方法形成保險公司財務巨大的損失。此外也因風險轉嫁,以致於醫療保險商品費用不斷提升,凡此均對我國之醫療保險市場形成扭曲與傷害其健全的發展。
     在醫療保險詐欺當中醫療院所及醫事從業人員,又扮演了絕對關鍵的角色。本研究以醫療保險詐欺形成的動機與誘因為研究目的,並以醫療院所為研究標的,透過社會交換理論來解釋其參與醫療保險詐欺之動機與獲得的有形與無形酬報,經由訪談法得到第一手資料,並得出研究成果有兩項:
    1.營運考量迫使地區型院所參與保險詐欺
    2.醫療霸權的持續與詐欺行為的助長
    本研究並提出相關建議有六點:
    1.理賠端需與醫護人員建立互信關係
    2.理賠端需要加強醫療專業新知
    3.司法機關應強化相關之宣導
    4.核保與理賠應注意事項
    5.保險公司之防制
    6.主管機關監督管理
    The claim amounts for commercial health insurance fraud are low, therefore the offence is highly repetitive. This becomes a method that nibbles away at the insurance company causing huge financial losses. Additionally, the risks are shifted resulting in the rising costs of medical insurance. The above activities distort the medical insurance market in Taiwan and haveadverse effects on robust development.
    Medical institutions and medical practitioners play a key role in medicare fraud. The purpose of this study is to explore the motivation and incentives to medicare fraud with medical institutions as the subject of the study. Through the social exchange theory, the motives and incentives for participating in medicare fraud resulting in tangible or intangible rewards are explained. Primary data is obtained through interviews. Two research outcomes are drawn from this study:
    1.Operational considerations force regional institutions into participating in insurance fraud.
    Continued medical hegemonyencourages fraud
    This study proposes six recommendations:
    1.Insurance claim handler needs to establish a trusting relationship with the medical staff
    2.The insurance claim handler needs to strengthen their knowledge on medicine
    3.The relevant judicial authorities should strengthen related propaganda
    4.Underwriters and claims precautions
    5.Insurance Company Preventions
    6.Regulatory authorities
    Appears in Collections:[保險學系暨研究所] 學位論文

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