Having a trustworthy medical insurance plan is essential. In times of crisis, you can rely on it to protect you and your family from unanticipated costs and reduce some of the stress that comes with health concerns.
The ability to provide dependable and secure health insurance is very important to providers like us at HAYAH. For this reason, we work tirelessly to prevent health insurance fraud from impacting our policyholders, premiums and claim turnaround times.
Here, we explore what healthcare fraud is, and how insurance companies can detect and prevent it.
What Is Health Insurance Fraud?
Health insurance fraud is an act of deception or misrepresentation of information presented to health insurance companies.
Healthcare fraud can take different forms. For example, a patient could attempt to make a fraudulent one-off claim on their policy. Health insurance fraud could also be the more systematic act of a medical provider repeatedly providing false information.
Health Insurance Fraud Examples
Let’s explore what fraudulent health insurance claims can look like.
Health Insurance Fraud Committed by Policyholding Individuals
Policyholders can commit health insurance fraud in the following ways:
Providing false information when buying a policy.
Claiming for medication or health services that were not received.
Incorrect reporting of health issues or diagnosis.
Creating false invoices or documentation in order to make a claim.
Misrepresenting dates or other information when making a claim.
Swapping identities or committing identity theft to access medical services.
Bribery of medical providers in the pursuit of a fraudulent claim.
Policyholders who commit health insurance fraud might do so in an attempt to reduce a premium or to buy a policy that may otherwise be unavailable. They may wish to access treatments or medication not covered by their policy, to benefit financially, or to assist another individual in committing fraud.
Healthcare Fraud Committed by Medical Service Providers
Health insurance fraud can occur at an organisational level and it is typically motivated by an attempt to improve profits. Examples include:
Upcoding: This is when medical providers bill insurance companies for more complex treatments than those provided to the patient.
Phantom billing: This involves charging insurance providers for appointments and services that didn’t happen.
Double billing and unbundling: This is when healthcare providers duplicate information and bill insurance companies for the same service multiple times.
Misrepresenting treatments or medication: Organisations may present an uninsured treatment as one that can be claimed for. For example, cosmetic procedures are billed as medical treatments or bills are created for a more expensive drug than the one prescribed.
Providing unnecessary testing or interventions to profit from an insurer.
Health Insurance Fraud in the UAE
With a medical insurance market worth USD$ 2.8 billion and mandatory health insurance for expats, it is no surprise that fraud does happen in the UAE.
Most incidents are opportunistic and isolated, but insurance companies and officials have identified systematic organisational fraud, too. A well-publicised survey of Emirati participants in 2013 suggested that one-third had been encouraged to undergo unnecessary tests to inflate bills.
Health insurance companies in the UAE are alert to the signs of potentially fraudulent claims. The UAE government has also taken decisive action against those committing healthcare fraud. For example, the Abu Dhabi department of health recently fined a health centre Dh1 million and put several of its doctors under investigation.
How Is Healthcare Fraud Prevented and Detected?
Health insurance fraud can raise the cost of premiums and slow down claim turnaround times. It is vital that, as an insurance provider, we look out for the signs of fraud so that we can continue to provide the best service and premiums to honest policyholders.
Here’s what we and other insurers are doing to prevent and detect healthcare fraud.
Anti-Fraud Procedures and Technology
Tools and procedures are in place to systematically look for signs of fraud. They include:
Customer verification
The use of data analytics and technology to detect suspicious activity
Controls and reviews that detect unusual patterns
Regular staff training that teaches agents to flag potential fraud
Clear reporting routes
The regular review of anti-fraud policy
Clear Policy Wording
Clear policy wording and straightforward communication build transparency and trust, as well as contribute to an industry-wide anti-fraud culture.
Information Sharing
Collaboration with law enforcement agencies ensures that potential fraud is investigated and prosecutions happen when necessary. Sharing information with other insurance companies is also beneficial for the prevention of fraud.
How You Can Help Prevent Health Insurance Fraud
Together, we can do more to help prevent healthcare fraud.
Be savvy about who you share your confidential information with. If you suspect fraud, then report it to your insurance company or a law enforcement agency.
Finally, choose a family health insurance provider like HAYAH that has clear anti-fraud policies and procedures.
Get in touch to find out what we are doing to protect our policyholders from the consequences of fraud.