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The objective is to identify the definition, manifestations and factors that influence health insurance fraud (HIF).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A scoping review on health insurance fraud published between 2006 and 2020 was conducted in ACM, EconPapers, PubMed, ScienceDirect, Scopus, Springer and WoS.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Sixty-seven studies were included, from which we identified 6 definitions, 22 manifestations (13 by the medical provider, 7 by the beneficiary and, 2 by the insurance company) and 47 factors (6 macroenvironmental, 15 mesoenvironmental, 20 microenvironmental, and 6 combined) associated with health insurance fraud. We recognized the elements of fraud and its dependence on the legal framework and health coverage. From this analysis, we propose the following definition: \u201cHealth insurance fraud is an act of deception or intentional misrepresentation to obtain illegal benefits concerning the coverage provided by a health insurance company\u201d. Among the most relevant manifestations perpetuated by the provider are phantom billing, falsification of documents, and overutilization of services; the subscribers are identity fraud, misrepresentation of coverage and alteration of documents; and those perpetrated by the insurance company are false declarations of benefits and falsification of reimbursements. Of the 47 factors, 25 showed an experimental influence, including three in the macroenvironment: culture, regulations, and geography; five in the mesoenvironment: characteristics of provider, management policy, reputation, professional role and auditing; 12 in the microenvironment: sex, race, condition of insurance, language, treatments, chronic disease, future risk of disease, medications, morale, inequity, coinsurance, and the decisions of the claims-adjusters; and five combined factors: the relationships between beneficiary-provider, provider-insurance company, beneficiary-insurance company, managers and gu\u0101nxi.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>The multifactorial nature of HIF and the characteristics of its manifestations depend on its definition; Identifying the influence of the factors will support subsequent attempts to combat HIF.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s40352-021-00149-3","type":"journal-article","created":{"date-parts":[[2021,9,30]],"date-time":"2021-09-30T04:23:11Z","timestamp":1632975791000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":35,"title":["Fourteen years of manifestations and factors of health insurance fraud, 2006\u20132020: a scoping review"],"prefix":"10.1186","volume":"9","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7947-111X","authenticated-orcid":false,"given":"Jos\u00e9","family":"Villegas-Ortega","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0825-9271","authenticated-orcid":false,"given":"Luciana","family":"Bellido-Boza","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9262-626X","authenticated-orcid":false,"given":"David","family":"Mauricio","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2021,9,30]]},"reference":[{"key":"149_CR1","doi-asserted-by":"publisher","first-page":"90","DOI":"10.1016\/j.jnca.2016.04.007","volume":"68","author":"A Abdallah","year":"2016","unstructured":"Abdallah, A., Maarof, M. 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