Fraud in the health systems of Chile: A detection model Fraudes a los sistemas de salud en Chile: Un modelo para su detección

Abstract

Objectives. To develop a model for detecting cases of organized fraud in Chile based on data from the legal forms for medically authorized leave (formulario legal de licencia médica curativa-MAL) and to establish the relevance of this data to fraud detection. Methods, A binomial logistic regression model was employed using four variables from the MAL form, a national requirement for illness-related work absences: the number of legal absences taken by a single person, the number of days authorized by the prescribing doctor, the total cost per illness, and a dichotic variable reflecting whether or not the diagnosis is one that can be proven. The analysis involved 4 079 MAL forms that had been submitted in 2003 to a private health provider and of which 356 were already identified as fraudulent by a panel of medical fraud experts. Results. The model successfully identified 99.71% of the fraudulent medical authorizations and 99.86% of the non-fraudulent, according to the criteria of the pan