A typology framework for unethical medical practices under public health insurance schemes in India: Analysis of evidence over the past 12 years.

Abstract

Background: Unethical provider practices in public healthcare schemes adversely impact beneficiaries' health, result in the loss of public funds, and also bring disrepute to the schemes. There is extensive literature on the typologies of unethical practices in healthcare in developed countries. This study aims to develop a typology framework which is applicable in the Indian context.

Methods: In this study, 25 media reports and research studies were analysed on unethical provider practices under public health insurance schemes in India over the past 12 years from 2010 to 2022. The reports were collated from de-empanelment orders issued by state health authorities against various erring entities, and research studies conducted on the abuse of these schemes.

Results: Based on the analysis and classification of the cases reported, an "Unethical Provider Practices" typology for healthcare fraud has been defined. Additional fraud typologies are found to be prevalent in India in addition to those captured by existing frameworks. These include patient harm, ID theft of beneficiary data to create cards for non-beneficiaries, and collusion between providers and different entities.

Conclusions: Fraud control mechanisms leveraging technology such as AI-enabled digital apps for medical audits, biometric technology at the point of care and rigourous checks of ID documents before beneficiary cards are issued as well as having more specific legal provisions in place for healthcare fraud will enable enhanced prevention, detection and deterrence of healthcare fraud.