A study on the path of governance in health insurance fraud considering moral hazard

Abstract

Combating health insurance fraud is of utmost importance to physicians, patients, and health insurers. To delve into the mechanisms of health insurance fraud between doctors and patients, this study employed evolutionary game theory to construct a model that comprehensively considers moral hazard, fraud cost, reward, punishment, bribes from patients, and other factors. Through theoretical analysis and numerical simulation of the model, the study discovered that the evolution of governance behavior in health insurance fraud is closely linked to its initial construction of the payment matrix and the initial selection of parameters for the payment matrix. Additionally, increasing penalties for fraudulent behavior, increasing the cost of fraud for both doctors and patients, and reducing moral hazard for both can effectively drive the final strategy of the system toward a non-fraudulent state. The study aims to provide valuable insights and recommendations to doctors, patients, and medical insurance institutions in establishing a sound governance environment for managing fraud behavior in health insurance.