Page 369 - Ebook health insurance IC27

Sashi Publications

 The member should deal with reputable agent.
 The member should disclose all illnesses at the time of taking the policy. This may

amount to little more extra premium but bring more peace at the time of claim.

Providers Role:
Fraud is a serious crime that legitimately concerns all stake holders of the health care
system - insurers and premium-payers, government and taxpayers, and patients and
health care providers. The doctors and the providers need to play a major role in
preventing fraud.
 The providers need to avoid fraudulent practice and intimate the TPA / Insurance

companies if any beneficiaries approach them for fabricating a false claim. It's a
social and ethical commitment of the hospitals.
 Use of Electronic Medical records and integrating with the TPA software or
insurance company's software which will prevent manipulating / tampering with
the patients medical history.

Fraud Claims Trigger:
 Insurance frauds usually have common profile and pattern.
 Treatment costs are usually on the higher side as compared to the etiology.
 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

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