Page 246 - Ebook health insurance IC27

The Insurance Times

Per-patient average medical tests.
Fluctuating monthly claims of the providers
Double billing

Consumer

With the increasing awareness of the insurance benefits, many policy holders have got
involved in healthcare fraud. Consumer frauds mainly fall in three categories:
 Claim fraud,
 Application fraud, and
 Eligibilityfraud.

Claim Fraud

Consumer claim fraud occurs when a consumer makes an intentional misrepresentation
in order to receive a benefit payment he is not entitled for. Such Claims can be categorized
as:
 False claims: e.g. Maternity claims which are not covered under the policy

benefit and member is making a claim of hysterectomy with fabricated medical
papers.
 Collusion with providers to submit false claims: Both provider and the member
collude to submit a false claims where the physician receives the benefits from the
false claims,
 Insurance speculation: An insured applies for several health insurance policies
without revealing his/her other coverage's. Insured makes a claim from all insurance
companies.
 Fraud rings: A Group involving consumers, agents, physicians, provider, making
a false claim.

250 Guide for Health Insurance