Findings from Southwestern University of Finance and Economics Update Knowledge of Insurance (Research On Quantitative Evaluation of Medical Insurance Fraud Supervision Policy Based On ‘antecedents-process-outcomes’ Framework): Insurance

Health Policy and Law Daily

2025 FEB 05 (NewsRx) -- By a News Reporter-Staff News Editor at Health Policy and Law Daily -- Investigators publish new report on Insurance. According to news reporting from Sichuan, People’s Republic of China, by NewsRx journalists, research stated, “Fraud in medical insurance is a serious problem that threatens the safety and sustainability of medical insurance funds. The process of reducing or even eliminating the impact of fraud is related to maintaining the balance of payments for medical insurance funds and reforming the payment system based on total amount control.”

Financial support for this research came from National Social Science Foundation of China.

The news correspondents obtained a quote from the research from the Southwestern University of Finance and Economics, “As a result of reviewing the policy background of medical insurance fraud in China, combined with the policy evaluation model in the area of public management, this paper develops a conceptual framework of ‘Antecedents-Process-Outcomes’ that emphasizes the fraud and governance of medical insurance funds. This paper uses grounded theory to look at 180 cases of medical insurance fraud and then uses the PMC index model to rate 18 policies. It then looks at the joint progressive analysis framework of medical insurance fraud and fraud supervision. In this paper, we analyze the policy similarities and differences of medical insurance fraud supervision in China from three perspectives: policy attributes, policy contents, and policy effects. The average PMC index of the 18 policies is 4.98, which is generally acceptable; however, there are some deficiencies in the policy field, policy supervision chain, policy orientation, and policy tools.”

According to the news reporters, the research concluded: “Then, it puts forward suggestions for improving the four policy shortcomings in order to provide theoretical and practical enlightenment for the high-quality development of the medical security system and realize the new medical security in the process of Chinese-style modernization.”

For more information on this research see: Research On Quantitative Evaluation of Medical Insurance Fraud Supervision Policy Based On ‘antecedents-process-outcomes’ Framework. PLOS ONE, 2025;20(1). PLOS ONE can be contacted at: Public Library Science, 1160 Battery Street, Ste 100, San Francisco, CA 94111, USA. (Public Library of Science - www.plos.org; PLOS ONE - www.plosone.org)

Our news journalists report that additional information may be obtained by contacting Zixiao Zhang, Southwestern University of Finance and Economics, School of Public Administration, Chengdu, Sichuan, People’s Republic of China. Additional authors for this research include Shaoqun Ding, Zitao Yang and Huaxia Hu.

The direct object identifier (DOI) for that additional information is: https://doi.org/10.1371/journal.pone.0313618. This DOI is a link to an online electronic document that is either free or for purchase, and can be your direct source for a journal article and its citation.