Health consumer susceptibility to medical care fraud: an exploratory analysis

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.