Page 245 - Ebook health insurance IC27

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C) Provider and Consumer
Fraud can be committed both the insured member or the provider and at times may be
a concerted effort of agents, brokers, insurance employees, insured member and the
provider of services and other stake holders of the health care system.

Fraud Claims Trigger:

Insurance frauds usually have common profile and pattern.
Treatment costs are usually on the higher side.
Costlier investigations are more.
Diagnosis of the ailment and the investigations done are not much related to each other
Duration of stay is more at times
At times histopathology reports usually not available in surgical cases.
Documentations are usually in order.
Similar handwriting / over writing
In most fraudulent claims the treating doctor, agents, ailments are the same.
Medicine bills in serial order.
Member purchasing medicine far from the place of residence or provider.
Patient residence and the hospital address are not geographically same.
Fraud claimers are short term policy holders with lower sum insured.
Claims registered immediately after the waiting period is over
Higher per-patient cost.
Excessive per-doctor patients.
Higher per-patient test.
Higher per-patient average visit numbers.

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