In order to prevent increasing fraudulent claims health insurance companies and their Third Party Administrators (TPA) have increased their efforts to counter frauds. Insurers are becoming pro active and investigating suspicious claims and for this they are even enlisting support of external agencies.
In health insurance fraud can originate either from application level due to incomplete disclosure or at claim level, individuals with hospitals feign illness to get claim. And there are also cases where hospitals inflate bills for insured.
As per the recent insurance frauds survey conducted by consulting firm Ernst & Young, rising cases of insurance frauds is not only increasing cost for insurers but it also rising premiums for policyholders. In the survey 40% respondents said there is rise in insurance frauds in last year. 80% Respondents of the survey said that insurance frauds may increase costs for insurers by 1% or in some cases it can go above 5%.
Measures
First measure that they have taken is to pay surprise visit to hospital during insured’s stay or to their homes to check their case papers. Sometimes insurers also outsource this to agencies that specialize in this investigation. Doctors who will represent insurers will visit hospitals and verify whether or not claim is genuine.
Another step that insurers have taken is to black list hospitals. If one Insurer finds that claim is fraudulent then it blacklists that hospital and insurers share this data with each other. Insurers also share this data with General Insurance Council (GIC) which maintains database of it.
Insurers are also trying to make sure that such hospital is not empanelled by any other insurers. Logic behind this is that it will impact their business and then it might force them to change their practices.
Four public sector general insurers are also pro active to take fraud preventing steps. General Insurers Public Sector Association (GIPSA) also insists on intimation before discharge of insured in case of all reimbursement cases.
Last year all public sector general insurers cracked down hospitals which according to them were over charging. Only when hospitals agreed for standard rates for cashless treatments prescribed by them general insurers put them on their Preferred Provider Network (PPN) list.
As per insurers fraud counter mechanism will also help genuine claimants as if frauds will be prevented then it will not hinder their claim process.
As per insurers to avoid coming under the scanner of health insurance companies policyholders should also make due diligence. Policyholders should also inquire about the bills of the hospitals this will help in them in long run. As if they wish to shift to another health insurance company then policyholder with healthy claim history can get good premium rates from new insurer.
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