Page 366 - Ebook health insurance IC27

The Insurance Times

 A business's group health plan covers all full-time employees but not part-time
workers. A part-time employee colludes with another employee in human
services to falsify records so that it appears that he works full-time and is
covered by the plan.

Insurance Staff members / Agents / TPA's / Brokers
 Creating false documents and processing false claims against genuine member's

records.
 Stakeholders involved in unfair trade practices to clear non-payable claims.

Managing frauds
Managing frauds is one of most challenging and difficult tasks. There are some
suggested ways for better monitoring of the fraud claims but there are still no full
proof mechanisms to deal with the burning issue.

Insurers Role:
The first one to get affected by insurance frauds is the insurers, so they need to play
an active role in preventing frauds. They need form a team to fight against it. Some
suggested methodologies may be:
 Formulate a program / internal audit for fighting fraud and sometimes include

special investigation units to identify fraud patterns. Investigate frequent
reimbursement claim from network hospital, delayed request for cashless,
insured admitted for chronic disease like CABG, Angioplasty, kidney failure etc
within a year after insurance coverage etc.

370 Guide for Health Insurance