مطالعه‌ی‌ موارد مغایر با ضوابط و مقررات مندرج در پرونده‌ی پزشکان طرف قرارداد بیمه‌ی خدمات درمانی استان اصفهان

Abstract

Introduction: The rapid increase in health costs across the world has forced governments to use insurance programs. Uncontrolled costs would reduce the financial ability of insurance organizations in providing services. Abuse of health insurance wastes 3-15% of the health budget annually. This study was conducted to determine cases of violating the rules and regulations of Medical Services Insurance Organization by contracted physicians in Isfahan Province, Iran. Methods: In this descriptive study, of 2752 cases of physician contracts, a sample size of 384 cases was selected using random sampling. Content validity and Cronbach's alpha (α = 0.75) were respectively used to confirm the validity and reliability of the data collection tool. After extraction, data was analyzed in SPSS. Results : Visiting patients using another person's insurance book (P = 0.02), using more than one sheet per visit (P = 0.008), and prescribing inappropriate medications (P = 0.024) were significantly more common among general physicians than in specialists. On the other hand, compared to general physicians, specialists were less committed to the determined fees (P = 0.01), more commonly visited patients in groups (P = 0.007), and accepted more limited number of patients under insurance coverage (P < 0.001). Conclusion: The results showed that less than 1% of service providers failed to comply with the rules probably due to lack of awareness. Therefore, insurance companies can provide information on the rules and regulations, replace insurance books with electronic health cards, make timely payments of claims, and hold retraining seminars on professional ethics with emphasis on the Islamic rules and the national law to improve the services provided and prevent violations of the law. Keywords: Insurance; Health Services; Legislation.