Tradicionalmente, las primas de los contratos de seguros se han considerado justas o equitativas cuando se corresponden exactamente con el riesgo de las pólizas, medido este último mediante la esperanza matemática de la siniestralidad. En este artículo llevamos a cabo una crítica de este enfoque aparentemente objetivo y proponemos una justificación alternativa de la denominada equidad actuarial, basada en argumentos contractualistas. Para ello nos apoyamos en ciertas intuiciones de Jean Domat, un jurista francés del siglo XVII, acerca de la incertidumbre (...) compartida, integradas dentro del marco general proporcionado por la teoría contractualista del economista y filósofo contemporáneo Robert Sugden. (shrink)

Each state’s Medicaid Fraud Control Unit prosecutes billing fraud cases against individual healthcare providers who fraudulently bill Medicaid for services provided. Once an individual is convicted of billing fraud, the Office of Inspector General for the Department of Health and Human Services may exclude the individual from billing any federal government healthcare program, including Medicaid. Excluded individuals are added to a public list of exclusions, which restricts their ability to practice professionally. Prompted by criminology research into the impact of policing (...) resources, we test whether these government enforcement initiatives against fraud serve as a deterrent to would-be fraudulent billers. We document that key enforcement proxies, the staffing level and budget of an MFCU, are positively associated with the yearly number of exclusions added at the state level. Our results are consistent with the exclusion list not being a deterrent but provide support for MFCUs’ fraud detection efforts. This paper provides industry-specific fraud insights for auditors and other individuals involved in public policy, specifically Medicaid, and introduces a novel dataset to the accounting fraud research literature. (shrink)

A growing literature has focused on understanding how to detect and deter unethical consumer behavior. In this work, we focus on a particularly important type of unethical consumer behavior, consumer insurance fraud, and we analyze a unique dataset to understand how experts investigate suspicious claims. Two separate but related literatures inform the process of investigating suspicious insurance claims. The first literature is grounded in field research and emphasizes the importance of secondary sources. The second literature is grounded in laboratory studies (...) that emphasize the importance of interpersonal interactions. Here we draw upon both literatures to consider the importance of claimant interviews within the context of many investigative actions and the potential for claimants to avoid interviews. In an empirical study using qualitative and quantitative data from auto insurance claim investigations, we analyze investigative chronologies conducted by skilled experts. In doing so, we find that even when investigators can access information from a variety of sources such as witnesses, databases, and physical evidence, claimant interviews are the most important step in determining whether or not claims are denied or paid. Furthermore, we identify interpersonal avoidance as an important signal of unethical claimant behavior. Our findings inform deception detection theory and practice. We identify implications for deception detection in business, particularly for consumer unethical behavior and insurance fraud investigations. (shrink)

Researchers and managers alike are becoming increasingly interested in the topic of unethical consumer behavior. Where most studies view unethical behavior as something that is identifiable per se, the authors of the present article believe that it only exists because it has been constructed by people operating within a specific context. Hence the efforts made by this paper to explore, at the level of one specific organization, how interactions between employees and consumers might lead to the construct of unethical consumers. (...) Based on a case study of France’s AMDM—a mutual insurance company set up to serve a client base comprising motorcyclists—the paper addresses how one group of consumers ends up being categorized as unethical by revealing the existence of a sensemaking process within the target organization. This process develops in three main phases: the nurturing of a shared ethos; the protection of employees’ recognized status; and the demonization of any group of consumers threatening this status. Managers incorporating this sensemaking process can avoid or mitigate the negative effects befalling organizations when these kinds of unethical consumer behavior are constructed. (shrink)

Business activity can be analyzed through a ‘risk awareness’ perspective and a ‘responsibility awareness’ perspective. However, risk and responsibility are actually interdependent. Risk-taking triggers responsibility issues and taking responsibility means risking being asked critical questions. This article suggests some first steps for combining these two perspectives conceptually. After several introductory illustrations showing how risk and responsibility issues are intertwined, the article looks separately each at risk and at responsibility. Then the argument that such perspectives could be usefully combined is elaborated (...) further from a theoretical angle and from a practical angle, by looking at various ethical issues and by presenting paradigmatic examples of balancing or sharing risk and responsibility related to leadership, to ERM and to insurance. (shrink)