Page 254 - Ebook health insurance IC27

The Insurance Times

11. Control business where fraud is not manageable
 Control the areas which are not manageable
 If there are more fraud in acceptance of cash, the practice should be stopped and

company should start accepting only cheque
 The fraud is more in a particular region attention should be given to the process in

those offices

12. Feedback to entities who are party to fraud
 Provide regular feedback is to service providers/employees/customers
 Maintain malpractice matrix which conveys list of disciplinary action taken against

employees for fraud.
 Feedback to insurance agents/advisers who can help in fraud at the time of policy

as well as the claim

Role of technology in preventing fraud

1. Ease of data capture
 Data entry should be user-friendly and easy to navigate
 All possible informations related to policyholders must be fed into the computer
 Display fraud triggers/alerts

2. Comprehensive claims information
 System should have comprehensive data fields
 Avoid poor data quality and noise
 System must have effective validations

3. Ability to detect fraud effectively
The system should be able to identify various frauds based on past experience
 Adverse claim a show for a agent or a partner or group

258 Guide for Health Insurance