Fraud And Health
[Summary: A health insurance claim prepared
with the intention to deceive, conceal or distort relevant information that eventually
accounts for health care benefits for an individual or a particular group is defined
as fraudulent health insurance claim.]
Health insurance is a form of insurance
that pays for medical expenses. If you are covered under health insurance, you pay
some amount of premium every year to an insurance company and if you have an accident
or if you have to undergo an operation or a surgery, the insurance company will
pay for the medical expenses. With health insurance providing a world of benefits
to people, fraudulent claims are on the rise. Frauds can be committed by anybody.
It can be committed by a policyholder, a health insurance company or even its employees.
Frauds committed by a policyholder could consist of members that are not eligible,
concealment of age, concealment of pre-existing diseases, failure to report any
vital information, providing false information regarding self or any other family
member, failure in disclosing previously settled or rejected claims, frauds in physician’s
prescriptions, false documents, false bills, exaggerated claims, etc.
Frauds by health insurance companies or its employees include preparation
of bogus claims by fake physicians, billing for products or services not rendered,
exaggerated claims submission, billing prepared for higher level of services, modifications
or alterations made in submission of health insurance claims , change in
diagnosis of the patient, fake documentation, and fraud committed by the employees
of a hospital or any other healthcare product or service provider in order to make
a quick buck. Fraudulent and dishonest health insurance claims are a major morale
and moral hazard not only for the health insurance industry but even for the entire
nation’s economy. Concrete proof as evidence including documentation,
statements made by the policyholder and his family members and even neighbors are
taken into consideration.
The essential components of fraud
include intention to deceive, derive benefits from the health insurance industry,
preparation of exaggerated or inflated claims or medical bills and an intention
to induce the firm to pay more than it otherwise would. Devising innovative methods
and tactics including pressure tactics, favoritism and nepotism form a part of fraud
which is a hazard growing by leaps and bounds since the last decade. To establish
that a fraud has been committed requires furnishing of relevant proof. An in-depth
analysis of the health insurance policyholder’s intention may also be
taken into consideration.
It is estimated that the number of
false health insurance claims in the industry is approximately 15 per cent of total
claims. The report suggests that the healthcare industry in India is losing approximately
Rs. 600 to Rs. 800 crores incurred on fraudulent claims annually. Health insurance
is a bleeding sector with very high claims ratio. Hence, in order to make health
insurance a viable sector, it is essential to concentrate on elimination or minimization
of fake claims.