عنوان مقاله [English]
Purpose: Due to the importance of medical fraud and general malpractice in the Iranian Social Security Organization (ISSO), this study was conducted with the aim of designing a model to deal with medical fraud and malpractice in the ISSO (prevention, detection and treatment).
Method: This research is a combined study via a qualitative-quantitative method, which was conducted in three stages as follows:
The first stage: comparative study, examining the documents of other countries on how to identify, prevent, address and deal with all kinds of fraud and violations in the field of medicine and health insurance; The second stage: qualitative stage, the purpose of this stage of the research was to fulfill the second to fourth objectives of this study. This part of research is a qualitative study that was conducted using semi-structured interviews; The third stage: Quantitative phase: providing a model and suggested solutions to control fraud and violations in the Iranian Social Security Organization
Findings: In relation to the first stage based on the article review checklist and the research protocol, 31 articles were selected with the following fields:
Classification and definition of medical fraud and malpractice (9 articles);
Methods of discovering and identifying medical fraud and malpractice (18 articles);
Methods of preventing medical fraud and malpractice (13 articles);
Methods of addressing fraud and medical malpractice (9 articles);
Regarding the second stage, cultural issues (2 activities), empowerment (3 activities), regulatory issues (4 activities), technology (4 activities), insurance laws (4 activities), and structural issues (4 activities), have made the general framework of addressing fraud and medical malpractice in health insurance of Iran.
As regards the third stage, the final model, creation of receivers and service providers, modification and updating of the control system, and modification and updating of performance factors were validated during two Delphi rounds.
Conclusion: In general, the final summary indicates that the cooperative management of the government as a trustee with the ISSO in the matter of tariff setting and thus, increasing the supervisory power of the insurance organization by determining precise and measurable indicators. Taking for the purpose of performance evaluation can greatly reduce fraud and medical malpractice.