Page 251 - Ebook health insurance IC27

Sashi Publications

 Sometimes only hospitals/doctors are involved in inflating bills knowing that
the insured is covered by health insurance.

 There is good amount of subjectivity in defining medical necessity has the service
providers try to get advantages by inflating the bills.

Some instances of fraud

 Ineligible Members/Dependents
 Concealing Pre-Existing Conditions
 Nondisclosure of diseases like Hypertension which cannot be ascertained by tests
 Submission of claim by bogus physicians or Non-Existent Hospitals
 Billing for services not rendered
 Billing for higher level of services
 Getting false will from hospitals/doctors
 Hospital/Doctors intentionally inflating the bills
 Diagnosis or treatment that are outside the scope of practice
 Treating for disease which did not exist
 Claiming hospital benefit even if the policyholder was not hospitalised
 Claiming expenses not relating to the diseases

Method to combat insurance fraud

There are two methods to combat insurance fraud
a. Human interface or process improvisation
b. Technology and process interface

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